Part 1 General

Part 2 Outpatient Facility Types

ANSI/ASHRAE/ASHE Standard 170-2017 Ventilation of Health Care Facilities

Heads up: There are no amended sections in this chapter.
Appendix material, shown in shaded boxes at the bottom of the page, is advisory only.
Electrical Receptacles for Patient Care Areas in Outpatient Facilities
Section Room Type Number of Single Receptacles1 Receptacle Locations
PATIENT CARE AND DIAGNOSTIC AREAS
2.1-3.2.1
Table 2.1-4
Examination room/observation room
Class 1 imaging room
8 4 convenient to head of exam table or gurney or on each lateral side of the imaging gantry
2.1-3.2.2
Table 2.1-4
Procedure room (including endoscopy)
Class 2 imaging room
123 8 convenient to table placement At least 1 on each wall
2.1-3.2.3
Table 2.1-4
Operating room
Class 3 imaging room
363 12 convenient to table placement 2 on each wall
2.1-3.7.3
2.1-3.7.5
Pre-procedure patient care station
Phase II recovery patient care station
4 Convenient to gurney, lounge chair, or bed
2.1-3.7.4 Phase 1 post-anesthesia recovery (PACU) patient care station 8 Convenient to head of gurney or bed
2.4-2.2 Birthing room 8 4 convenient to head of the mother's bed
2.8-3.4.2 Treatment room (emergency facility) 12 4 convenient to head of exam table or gurney
2.8-3.4.4 Trauma/resuscitation room (emergency facility) 16 Convenient to head of gurney or bed
2.8-6.2.2 Triage area (emergency facility) 6 Convenient to head of gurney or bed (at least 3 outlets connected to emergency system power and so labeled)
2.10-3.2.2 Hemodialysis patient care station 8 4 on each side of a patient bed or lounge chair (2 on each side of the bed connected to emergency power)
1Permanently installed single, duplex, or fourplex receptacles or a combination of these shall be permitted. Receptacles in relocatable power taps or mounted on portable equipment shall not be counted as part of the total minimum requirement.
2In this table, "convenient" means the cords from the equipment to be used in the room can reach the receptacles without causing a trip hazard.
3The number of receptacles for these spaces is intended to agree with the number required in the governing edition of NFPA 99: Health Care Facilities Code.
Notes
  1. Consideration shall be given to providing some outlets on essential electrical power and some on normal power in operating rooms and post-anesthesia recovery areas in case of transfer switch failure.
  2. Each room in the table shall meet the requirements for connection to the essential
    electrical system in the governing edition of NFPA 99: Health Care Facilities Code.
  3. Branch circuits serving only special purpose receptacles shall be permitted to be served by other panelboards.
A2.1-1 Common elements for outpatient facilities. This chapter contains design elements that are common to most types of outpatient facilities. The outpatient facilities included in the Guidelines for Design and Construction of Outpatient Facilities are used primarily by patients who are able to travel or be transported to a facility for treatment, including those confined to wheelchairs. These facilities may be an outpatient unit of a hospital, a freestanding facility, or an outpatient facility in a multiple-use building.
All outpatient projects, including those located in hospitals, shall meet the requirements in the Guidelines for Design and Construction of Outpatient Facilities.
All projects shall meet the standards in Part 1 of these Guidelines as amended in Section 2.1-1 (Common Elements for Outpatient Facilities-General).
Two approaches to applying the requirements in Parts 2 and 3 of the Outpatient Guidelines shall be permitted-Approach 1 and Approach 2.
  1. If a project is for one of the specific facility types listed in this section, the requirements of that chapter shall apply.
    1. Chapter 2.2, Specific Requirements for General and Specialty Medical Services Facilities
    2. Chapter 2.3, Specific Requirements for Outpatient Imaging Facilities
    3. Chapter 2.4, Specific Requirements for Birth Centers
    4. Chapter 2.5, Specific Requirements for Urgent Care Centers
    5. Chapter 2.6, Specific Requirements for Infusion Centers
    6. Chapter 2.7, Specific Requirements for Outpatient Surgery Facilities
    7. Chapter 2.8, Specific Requirements for Freestanding Emergency Facilities
    8. Chapter 2.9, Specific Requirements for Endoscopy Facilities
    9. Chapter 2.10, Specific Requirements for Renal Dialysis Centers
    10. Chapter 2.11, Specific Requirements for Outpatient Psychiatric Facilities
    11. Chapter 2.12, Specific Requirements for Outpatient Rehabilitation Therapy Facilities
    12. Chapter 2.13, Specific Requirements for Mobile/Transportable Medical Units
    13. Chapter 2.14, Specific Requirements for Dental Facilities
  2. When using Approach 1, the common elements in this chapter shall be required for a project when they are referenced from the specific outpatient facility chapter applied to the project.
A2.1-1.1.2.1 Approach 1 is meant to be used for projects for which the scope of services is comprehensively described in one of the specific outpatient facility chapters in Part 2 of this document. The prescriptive requirements adequately address risks and can be accommodated by the design without adversely impacting the intended function of the space.
*(1)  If a project is for a facility type that is not listed in Section 2.1-1.1.2.1 (Approach 1) but will include elements in one or more of those facility chapters and/or elements in this common elements chapter (Chapter 2.1), those specific requirements shall be applied to the project.
*(a) The requirements in the common elements chapter and in the facility chapters in Part 2 that support the services to be included in the project shall be identified during the planning phase.
*(b)  The common element and specific facility chapter requirements identified as part of the project during the planning phase shall be documented in the basis of design.
*(2)  If required by the authority having jurisdiction (AHJ), the identified requirements shall be presented to the AHJ for review and approval prior to completion of design.
A2.1-1.1.2.2 (1) Projects suited to Approach 2.
Approach 2 is intended to be used for projects where the scope of services is not adequately described in only one of the outpatient facility chapters listed in Section 2.1-1.1.2.1. This approach identifies minimum requirements found in the common elements chapter and in any facility chapters that are relevant to the project.
A2.1-1.1.2.2 (1)(a) and (1)(b) Approach 2 process for identifying and documenting relevant requirements. Development of specialty outpatient facilities that are not included in the Outpatient Guidelines will depend on a detailed and specific functional program to establish physical environment requirements. Thus, Approach 2 is based on the performance assessment for the project space that underpins the functional program as well as practical application of relevant standards.
  1. Identification of services for Approach 2. The project team using Approach 2 should identify the services to be included in the project, including both clinical and support services.
  2. Identification of sections of the Guidelines that apply to the project. Once the services included in the project have been identified, the team should identify the sections of the Outpatient Guidelines that contain requirements for those functions. For example, a small clinic may choose to offer dialysis services. Chapter 2.2, Specific Requirements for General and Specialty Medical Services Facilities, which includes clinic requirements, does not contain requirements for dialysis, but Chapter 2.10, Specific Requirements for Renal Dialysis Centers, does. In this example, Approach 2 allows the design team and the AHJ to apply requirements from both Chapter 2.2 and Chapter 2.10, including shared support services based on risk and function.
    In addition to space requirements for clinical spaces included in the project, careful attention should be paid to requirements for all associated support areas, architectural details, surfaces, and building systems needed to meet minimum standards for the clinical spaces. These include, but are not limited to:
    • -Clinical support areas, such as clean and soiled workrooms or work areas
    • -Staff support areas
    • -Patient support areas
    • -Architectural details and surfaces for walls, floors, and ceilings
    • -Mechanical filtration, air changes, humidity controls
    • -Electrical systems
    • -Plumbing systems
    Note: Specialty outpatient facility projects to which Approach 2 is applied may also have project elements that are not addressed in the Guidelines.
A2.1-1.1.2.2 (2) AHJ review of project scope. The project-specific Approach 2 is subject to interpretation and relies on early communication with the AHJ to be successful. Information shared with the AHJ is intended to facilitate discussion of the project requirements.
The AHJ should be presented with an accurate scope of services that forms the basis of design. Working toward a joint understanding of building functions will facilitate the identification of risks and consequent minimum standards to be applied to the project. Specific information presented to the AHJ may include:
-Accurate list of services to be provided
-Preliminary functional program
-Bubble diagram showing space relationships
-List of Guidelines sections to be applied
Validating the scope of the project and the application of the Outpatient Guidelines requirements early in the project delivery process allows the design to proceed in an informed manner with minimized risk.
If space and/or services are to be shared or purchased, details of such shared or purchased space and/or services shall be indicated in the functional program to ensure design and infection prevention considerations are addressed for services to be provided in the facility.
A2.1-1.2.3 Shared/purchased services. Shared/purchased space and/or services may include space and/or services for storage, laundry, public areas, housekeeping facilities, and waste management.
Facility layout shall preclude unrelated traffic through patient care areas.
A2.1-1.4 Facility layout. In general, public traffic should not go through patient care areas. Consideration should be given to avoiding mixing patient populations from one clinical service with patient populations from another clinical service, although this is permissible when services are shared (e.g., imaging services).
Table 2.1-2
Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities
Section Location Oxygen Vacuum Medical Air Instrument Air
PATIENT CARE AND DIAGNOSTIC AREAS
2.1-3.2.2 Procedure room 11 11 - -
Table 2.1-4 Class 2 imaging room 2 2 11 -
2.1-3.2.3.2 (1)(a) Operating room (255-square-foot OR) 11 11 - -
2.1-3.2.3.2 (1)(b)-(c)
Table 2.1-4
Operating rooms2
Class 3 imaging room2
2 3 11 -
2.1-3.3.2 Airborne infection isolation room 01 01 - -
2.1-3.7.4 Phase I post-anesthesia recovery (PACU) patient care station 1 1 - -
2.1-3.7.5 Phase II recovery patient care station 01 01 - -
Cast room 01 01 - -
2.4-2.2 Birthing room 11 11 - -
2.8-3.4.2 Treatment room (emergency facility) 1 1    
2.8-6.2.2 Triage area (emergency facility)-per station 1 1    
2.8-3.4.4 Trauma/resuscitation room (emergency facility)-per gurney 2 2 1  
2.9-3.2.2 Endoscopy procedure room 1 3 - -
2.11-3.2.9.2 (2) Electroconvulsive therapy treatment room 11 11 - -
PATIENT SUPPORT FACILITIES
2.1-4.3.2.2 (2) Sterile processing decontamination room - - - 11, 4, 5
2.1-4.3.2.2 (3) Sterile processing clean workroom - - - -1, 4, 5
2.1-4.3.2.3 One-room sterile processing room - - - -1, 4, 5
2.9-4.3.2 Endoscope processing room-decontamination area - -3 - -1, 3, 5
2.9-4.3.3 Endoscope processing room-clean work area - -3 - -1, 3, 5
1Use of portable equipment in lieu of a piped gas system shall be permitted.
2If inhalation anesthesia will be used in an operating room or Class 3 imaging room, installation of a waste anesthetic gas disposal (WAGD) system should be considered.
3Vacuum and/or instrument air shall be provided if needed for cleaning methods used.
4In the one-room sterile processing facility and the clean workroom of the two-room sterile processing facility, an instrument air outlet or portable compressed air shall be provided as required by the equipment used. In the decontamination room of the two-room sterile processing facility, an instrument air outlet or portable compressed air is required.
5NFPA 99 permits the use of portable medical compressed air for single applications. Where cylinders are used for non-respiratory purposes, such as air for blowing down scopes and/or running decontamination equipment, NFPA 99 should be consulted for cylinder air quality, placement, and handling.
Note
The provision of medical gases shall also comply with NFPA 99: Health Care Facilities Code. The clinical risk assessment in NFPA 99 may result in more stringent requirements for locations where this table permits use of portable gases.
During project planning, health care organizations providing services in outpatient facilities shall determine their need to provide spaces designed to enable safe care of patients of size as required in Section 1.2-6.4.1 (Projected Need for Accommodations for Care of Patients of Size). (See the glossary for a definition of "patient of size.")
All patient care areas designated for care of patients of size shall meet the requirements in this section.
A patient handling and movement assessment shall determine the need for expanded-capacity lifts and architectural details that support movement of patients of size in spaces where these patients may be seen. See sections 1.2-6.4.1.3 (Projected number of expanded-capacity lifts required) and 1.2-6.4.2 (Design Response for Accommodations for Patients of Size).
A2.1-2.1.1.2 Patient lift system. Accommodations for patient handling, movement, and mobilization can be provided by either an overhead lift system or a floor-based full-body sling lift and standing assist lifts. Lifts chosen should be capable of accommodating the threshold weight capacity of patients of size identified in the planning phase. See sections 1.2-4.3 (Patient Handling and Movement Assessment) and 1.2-6.4.1.1 (Projected weight capacities for patients of size in the population to be served).
Overhead lift systems have some advantages over floor-based lifts. In addition to needing smaller room dimensions than floor-based lifts, overhead systems biomechanically impact the musculoskeletal system of health care providers less than floor-based models. As well, staff prefer and are more compliant in using overhead lifts, reducing the musculoskeletal injury risk to staff and improving the quality of patient care.
For additional information on the use of patient lifts, see the guidance in the HHS publication "Americans with Disabilities Act: Access to Medical Care for Individuals with Mobility Disabilities."
Spaces designated for care of or use by individuals of size shall be provided where needed to accommodate the population expected to be served by the facility.
Hand-washing stations in toilet rooms designated for use by patients of size shall meet the requirements in Section 2.1-3.8.7 (Hand-Washing Station) as amended in this section.
The downward static force required for hand-washing stations designated for patients of size shall be identified during the planning phase and accommodate the maximum patient weight of the patient population.
Toilet rooms designated for use by patients of size shall meet the requirements in this section.
Where an expanded-capacity toilet is used, it shall be mounted a minimum of 36 inches (91.44 centimeters) from the finished wall to the centerline of the toilet on both sides where a ceiling-based or floor-based lift is provided (for caregiver assistance).
Where a regular toilet is used, the toilet shall be mounted a minimum of 44 inches (111.76 centimeters) from the centerline of the toilet on both sides to finished walls to allow for positioning of an expanded-capacity commode over the toilet when the weight capacity of the existing toilet will not accommodate the necessary patient weight.
A rectangular clear floor area that is 46 inches (116.84 centimeters) wide shall extend 72 inches (182.88 centimeters) from the front of the toilet.
See Section 2.1-7.2.2.9 (Grab bars) for grab bar requirements.
An exam room designated for care of patients of size shall meet requirements in Section 2.1-3.2.1 (Examination Rooms) as amended in this section.
Rooms shall be sized to permit the clearances in this section:
(1)  At the foot of the expanded-capacity exam table: 5 feet (1.52 meters)
(2)  On the non-transfer side of the expanded-capacity exam table: 3 feet (91.44 centimeters)
*(3)  On the transfer side of the expanded-capacity exam table:
(a)  Where a ceiling- or wall-mounted lift is provided: 5 feet (1.52 meters) from the edge of the table
(b)  In rooms without a ceiling- or wall-mounted lift: 7 feet (2.13 meters) from the edge of the table
A2.1-2.7.1.1 (3) Floor space for using patient lifts.
The transfer side clearance for an exam room with a ceiling- or wall-mounted lift is specified to accommodate a patient who is upright for transfer. In rooms where mobile lifts will be used, more floor space is required to accommodate the lift footprint and the staff needed to help a patient of size transfer from a wheelchair to an exam table.
When not in use for a patient of size, this examination or treatment room shall be permitted to be subdivided with cubicle curtains or movable partitions to accommodate two patients if each resulting bay or cubicle:
  1. Meets the following minimum clearance requirements:
    1. 5 feet (1.52 meters) between the sides of adjacent patient beds
    2. 4 feet (1.22 meters) between the sides of patient beds and adjacent walls or partitions
  2. Has direct access to a hand-washing station.
  3. Meets all electrical and medical gas requirements.
When sizing equipment storage for areas where care will be provided for patients of size, space shall be provided to accommodate the size of the expanded-capacity equipment (e.g., floor-based lifts, lift slings and accessories, etc.) and supplies that will be used.
A2.1-2.8 Expanded-capacity floor-based lifts, slings, and accessories for patients of size are larger than standard equipment and thus require larger storage spaces.
Seating for persons of size shall be provided in waiting areas in outpatient facilities.
A2.1-2.9.1 Seating capacity. See recommendations in appendix table A2.1-a (Waiting Area Seating Capacity).
Waiting areas shall be sized to accommodate the expanded-capacity furniture required for patients and visitors of size.
A2.1-2.9.2 Where seating for persons of size is provided, a portion of the seating should be able to accommodate a person who weighs 600 pounds (272.16 kilograms) or more.
All plumbing fixtures, handrails, grab bars, patient lift equipment, built-in furniture, and other furnishings and equipment shall be designed to accommodate the maximum patient weight established in the planning phase.
A2.1-2.10.1 Support for patients of size should be considered in the design of wall-mounted architectural elements.
Door openings shall be provided in accordance with Section 2.1-7.2.2.3 (2) (Door openings) as amended in this section.
All door openings used for the path of travel to public areas and areas where care will be provided for patients of size shall have a minimum clear width of 44.5 inches (113 centimeters) to provide access for expanded-capacity wheelchairs. Access for expanded-capacity gurneys or beds will require additional clear width.
Door openings to toilet rooms designated for patients of size shall have a minimum clear width of 44.5 inches (113 centimeters).
Table 2.1-3
Locations for Nurse Call Devices in Outpatient Facilities1, 2
Section Location Patient Station Staff Assistance Station Emergency Call Station Notes
PATIENT CARE AND DIAGNOSTIC AREAS
2.1-3.2.2
Table 2.1-4
Procedure room (including endoscopy)
Class 2 imaging room
  2, 3
2.1-3.2.3
Table 2.1-4
Operating room
Class 3 imaging room
  2
2.1-3.7.3
2.1-3.7.5
Pre-procedure patient care station
Phase II recovery patient care station
1, 2
2.1-3.7.4 Phase I post-anesthesia recovery (PACU) patient care station 2, 3
2.8-3.4.2
2.8-6.2.2
Emergency treatment room
Emergency triage area
1, 2, 3
2.10-3.10.2 Dialysis facility patient toilet room     1
2.11-3.2.9.2 (2)
2.11-3.2.9.3 (2)
Electroconvulsive therapy (ECT) room
ECT recovery patient care station
  2
1It is recognized that staff other than nurses may respond to these devices, but the term "nurse call" is used here as it is an industry-accepted term.
2A safety risk assessment shall identify patient toilet rooms where a patient station is required.
Notes
  1. One device shall be permitted to accommodate patient station, staff assistance station, and emergency call station functionality.
  2. A visible signal shall be activated in the corridor at the door to the room from which the signal was initiated and at the nurse/control station where one is provided.
  3. One device shall be permitted to accommodate both staff assistance and emergency call station functionality.
Where the following clinical and support areas are provided in an outpatient facility, the requirements in this section shall apply.
Each facility design shall ensure appropriate levels of patient speech and visual privacy and dignity throughout the care process.
A2.1-3.1.2 Patient privacy
  1. Visual privacy can be achieved using various means, including cubicle curtains, blinds, and electronically controlled vision panels. In single-patient rooms, the entry room door can be used to achieve visual privacy provided the door is solid or has non-transparent glass. Where doors with vision panels or transparent glass are used, provisions for visual privacy should be made. Consideration should be given to designing the room so the foot of the table does not face the door, using door orientation, privacy hinges, or a cubicle curtain to provide visual privacy.
  2. Speech privacy can be enhanced through use of full-height partitions and/or sound-masking. As well, speech privacy for patients in bays and cubicles can be achieved by using an exam or consultation room for patient communication.
Note: For more information, see Section 1.1-4.4 (National Standards for the Protection of Patient Health Information).
Where an examination room is provided, it shall meet the requirements in this section.
A2.1-3.2.1 Offices and/or practitioner consultation rooms may be combined with examination rooms.
  1. Patient privacy
    1. See Section 2.1-3.1.2 (Patient Privacy) for requirements.
    2. Provision shall be made to preserve patient privacy from observation from outside an examination room.
  2. See the following tables for exam room requirements:
    1. Table 2.1-1 (Electrical Receptacles for Patient Care Areas in Outpatient Facilities)
    2. Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities)
    3. Table 2.1-3 (Locations for Nurse Call Devices in Outpatient Facilities)
(1)  General
(a)  Where an examination room is used as an observation room, it shall be immediately accessible to the nurse or control station and a toilet room.
(b)  A room arrangement in which an examination table, recliner, or chair is placed at an angle, closer to one wall than another, or against a wall to accommodate the type of patient being served shall be permitted.
(2)  Space requirements
(a)  Single-patient exam/observation room
(i)  Area. Each single-patient examination/observation room shall have a minimum clear floor area of 80 square feet (7.43 square meters) as long as the clearances below can be met with the exam table or recliner that will be used.
(ii) Clearances. Room size shall accommodate a minimum clearance of 2 feet 8 inches (81.28 centimeters) at each side and at the foot of the examination table or recliner.
*(b)  Single-patient exam room for specialty clinical services
(i)  Area. Single-patient rooms for specialty clinical services that require larger examination rooms shall have a minimum clear floor area of 100 square feet (9.29 square meters).
*(ii) Clearances. Room size shall accommodate the following minimum clearances:
•  3 feet 6 inches (99.06 centimeters) at the side(s), head, or foot of the exam table or chair that correspond(s) with the care provider(s)' expected work position(s)
•  1 foot (30.48 centimeters) at all sides (side, head, or foot) of the exam table or chair other than the work position(s)
(3)  Room features. The exam room shall contain the following:
(a)  Portable or fixed examination light as indicated in Section 2.1-8.3.4.3 (1) (Lighting for specific locations in outpatient facilities-Exam/treatment/trauma rooms)
(b)  Storage for supplies
(c)  Accommodations for written and/or electronic documentation
(d)  Space for a visitor's chair
(e)  Hand-washing station that complies with Section 2.1-3.8.7.2 (Hand-Washing Station-Design requirements)
A2.1-3.2.1.2 (2)(b) Specialty exam room. Rooms in specialty clinics such as rooms for eye or ear, nose, and throat (ENT) examinations, should be sized for the services provided, including necessary equipment.
A2.1-3.2.1.2 (2)(b)(ii) Clearances at patient care positions in specialty exam rooms are not adequately or appropriately assured by centering the care position with clearances at sides and foot. The issue is adequate clearance at positions used by care providers, which may involve more than one provider and could include the head of the patient position. Where access to a patient position is unnecessary (e.g., at the head and on one side in eye exam lanes), smaller clearances are acceptable.
(1)  Application
*(a)  This section shall apply to outpatient facilities that include a procedure room as defined in the glossary.
(i)  The governing body shall perform a clinical assessment of the procedures to be performed in a facility to determine the appropriate room type and location for these procedures and document this in the functional program.
(ii) Where it is determined the design requirements for a procedure room as shown in Table 2.1-4 (Examination/Treatment, Procedure, and Operating Room Classification) and in Part 3 (ANSI/ASHRAE/ASHE 170: Ventilation of Health Care Facilities) are appropriate, the requirements in this section shall be met.
(b)  Where a procedure room is used for multiple procedure types, the room shall meet the most stringent requirements for the space.
*(c)  Where procedures that require a negative pressure environment are performed, a procedure room(s) with negative pressure shall be provided and identified with a sign. See Part 3 (ANSI/ASHRAE/ASHE 170: Ventilation of Health Care Facilities) for more information.
(2)  Location
(a)  The procedure room shall meet the requirements of a semi-restricted area.
(b)  The procedure room shall be permitted to be accessed from a semi-restricted corridor or from an unrestricted corridor.
A2.1-3.2.2.1 (1)(a) Procedures that are not defined as invasive in the glossary may be performed in an operating room. However, invasive procedures should not be performed in a procedure room even if it is located in the semi-restricted area.
A2.1-3.2.2.1 (1)(c) Procedures that require different pressure relationships cannot be provided in the same procedure room. For example, procedure rooms where bronchoscopies will be performed require negative pressure; if these rooms are also used for other procedures, the other procedures must be able to be performed in a negative pressure environment. Signage identifying rooms with negative pressure can help users choose appropriate rooms for procedures such as bronchoscopy.
(1)  Area
(a)  Procedure rooms shall have a minimum clear floor area of 130 square feet (12.08 square meters).
(b)  Procedure rooms where anesthetics will be administered using an anesthesia machine and supply cart shall have a minimum clear floor area of 160 square feet (14.86 square meters).
(c)  Procedure rooms where procedures will be performed that require additional personnel and/or large equipment shall be sized to accommodate the personnel and equipment planned to be in the room during procedures, including any additional personnel and equipment needed for emergency rescue.
(2)  Clearances
(a)  Procedure rooms shall have the following minimum clearances around the procedure table, gurney, or procedural chair:
(i)  3 feet 6 inches (1.07 meters) on each side
(ii) 3 feet (91.44 centimeters) at the head and foot
*(b)  Where an anesthesia machine and associated supply cart are used, the clearance at the head shall be 6 feet (1.83 meters).
(3)  Fixed encroachments into the minimum clear floor area. Fixed encroachments shall be permitted to be included when determining the minimum clear floor area for a procedure room as long as:
(a)  The encroachments do not extend more than 12 inches (30.48 centimeters) into the minimum clear floor area.
(b)  Where a sterile field is provided, the encroachment shall not extend into the sterile field.
(c)  The encroachment width along each wall does not exceed 10 percent of the length of that wall.
A2.1-3.2.2.2 (2)(b) Anesthesia work zone. On the outside edge of the anesthesia work zone, 2 feet × 8 feet (61 centimeters × 2.44 meters) may serve as part of the circulation pathway.
  1. Accommodations for written and/or electronic documentation shall be provided in the procedure room. See appendix section A2.1-3.8.3 (Documentation area) for recommendations.
  2. Where a built-in feature is provided for documentation, it shall allow for direct observation of the patient when in use.
Provisions shall be made for patient privacy in accordance with Section 2.1-3.1.2 (Patient Privacy).
  1. A hand-washing station shall be provided in the procedure room in accordance with Section 2.1-3.8.7 (Hand-Washing Station).
  2. Where a hand scrub station is directly accessible to the procedure room, omission of the hand-washing station shall be permitted.
  1. Doors and door hardware. See Section 2.1-7.2.2.3 (2) (Door openings) for requirements.
  2. Surfaces. See Section 2.1-7.2.3 (Surfaces) for requirements.
  3. Building system requirements
    1. HVAC system
      1. See Part 3 (ANSI/ASHRAE/ASHE 170: Ventilation of Health Care Facilities) for ventilation requirements for procedure rooms.
      2. Anesthetic gas scavenging system. For procedure rooms where general anesthesia is provided, see note m in Table 8.1 (Design Parameters) in ASHRAE/ASHE 170.
    2. Electrical receptacles. See Table 2.1-1 (Electrical Receptacles for Patient Care Areas in Outpatient Facilities) for requirements.
    3. Plumbing
      1. Drainage system. See Section 2.1-8.4.2.6 (Drainage systems) for requirements.
      2. Medical gas outlets. See Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air in Outpatient Facilities) for requirements.
    4. Call system. See Table 2.1-3 (Locations for Nurse Call Devices in Outpatient Facilities) for requirements.
(1)  General
(a)  Facilities that have a procedure room(s) shall have the support areas in this section.
(b)  Sharing of these support areas with other clinical services in the facility shall be permitted.
(2) — (7) Reserved
(8)  Medication safety zone. See Section 2.1-3.8.8 (Medication Safety Zones) for requirements.
(9) — (10) Reserved
(11) Clean storage
(a)  A storage area for clean/sterile supplies shall be provided.
(b)  Facilities with more than one procedure room shall have a clean workroom.
*(12) Soiled holding. A space for holding soiled materials shall be provided that is separate from the clean storage area.
(13) Equipment and supply storage. Where equipment-intensive procedures are performed or large mobile equipment is used in a procedure room, storage space for this equipment shall be provided.
(14) — (15) Reserved
(16) Sterile processing facilities. Where sterile processing is performed on-site, sterile processing facilities shall be provided in accordance with Section 2.1-4.3.2 (Facilities for On-Site Sterile Processing).
(17) Pre- and post-procedure patient care. Where pre- and post-procedure patient care is required to support the procedures performed in the procedure room, the requirements in this section shall be met.
(a)  Location. Pre- and post-procedure patient care station(s) shall be permitted to be located in the procedure room or in a specifically designated patient care area.
(b)  Design requirements. Where pre- and post-procedure patient care stations are located in a specifically designated patient care area, see Section 2.1-3.7 (Pre- and Post-Procedure Patient Care) for requirements.
A2.1-3.2.2.8 (12) A cabinet could serve this purpose in a small facility with low patient turnover in the procedure room.
(1) — (3) Reserved
(4)  Storage for patients' belongings. Provisions shall be made for securing patients' personal effects during procedures.
A2.1-3.2.3 Provisions for patients with airborne infectious diseases. When an invasive procedure needs to be performed on a person who is known or suspected of having an airborne infectious disease and the procedure must be performed in an operating room, the recommendations outlined in the CDC "Guidelines for Environmental Infection Control in Health-Care Facilities" or the CDC "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings" should be followed.
*(1)  Application. This section shall apply to rooms designated for the performance of invasive procedures as defined in the glossary.
(2)  The outpatient operating room shall meet the requirements of a restricted area.
A2.1-3.2.3.1 (1) Procedures not defined as an "invasive procedure" in the glossary may be performed either in an operating room, a procedure room, or an examination/treatment room; see Table 2.1-4 (Examination/Treatment, Procedure, and Operating Room Classification) for details. Nothing in the Guidelines requires a facility where invasive procedures are not performed to have an operating room.
*(1)  Area
(a)  An operating room shall have a minimum clear floor area of 255 square feet (23.69 square meters).
(b)  An operating room where anesthetics will be administered using an anesthesia machine and supply cart shall have a minimum clear floor area of 270 square feet (25.08 square meters).
*(c) An operating room where surgery that may require additional staff and equipment will be performed shall have a minimum clear floor area of 400 square feet (37.16 square meters).
(2)  Clearances. The following minimum clearances shall be provided around the operating table, gurney, or procedural chair:
(a)  For a 255-square-foot operating room:
(i)  6 feet (1.83 meters) on each side
(ii) 5 feet (1.52 meters) at the head and foot
(b)  For a 270-square-foot operating room:
(i)  6 feet (1.83 meters) on each side
(ii) 6 feet × 8 feet (1.83 meters × 2.4 meters) at the head. This shall result in an anesthesia work zone with a clear floor area of 48 square feet (4.46 square meters).
(iii) 5 feet (1.52 meters) at the foot
(c)  For a 400-square-foot operating room:
(i)  8 feet 6 inches (2.59 meters) on each side
(ii) 6 feet (1.83 meters) at the head. This dimension shall result in an anesthesia work zone with a clear floor area of 48 square feet (4.46 square meters).
(iii) 7 feet (2.13 meters) at the foot
(3)  Fixed encroachments into the minimum clear floor area. Fixed encroachments shall be permitted to be included when determining the minimum clear floor area for an operating room as long as:
(a)  There are no encroachments into the sterile field.
(b)  The encroachments do not extend more than 12 inches (30.48 centimeters) into the minimum clear floor area outside the sterile field.
(c)  The encroachment width along each wall does not exceed 10 percent of the length of that wall.
A2.1-3.2.3.2 Determining operating room space requirements. Operating room size should be based on the procedures to be performed, including the number of staff required and the amount and size of equipment that will be used.
  1. The minimum clear floor area requirements for an operating room in the main text were determined by combining square footage for the sterile field, circulation pathway, movable equipment zone, and anesthesia work zone. The square footage for these areas was determined using the clearances shown below, based around an operating table of 3 feet × 7 feet (91.44 centimeters × 2.13 meters).
    • -Clearances for the 255-square-foot operating room:
      • • Sterile field: 3 feet (91.44 centimeters) on each side and at the head and foot of an operating table, gurney, or procedural chair
      • • Combined circulation pathway and mobile equipment zone: 3 feet (91.44 centimeters) on both sides and 2 feet (60.96 centimeters) at the head and foot of the sterile field
    • -Clearances for the 270-square-foot operating room:
      • • Sterile field: 3 feet (91.44 centimeters) on each side and at the foot of an operating table, gurney, or procedural chair
      • • Combined circulation pathway and mobile equipment zone: 3 feet (91.44 centimeters) on both sides and 2 feet (60.96 centimeters) at the foot of the sterile field
      • • Anesthesia work zone: 6 × 8 feet (1.83 × 2.44 meters) at the head of the operating table, gurney, or procedural chair
    • -Clearances for the 400-square-foot operating room:
      • • Sterile field: 3 feet (91.44 centimeters) on each side and at the foot of an operating table, gurney, or procedural chair
      • • Circulation pathway: 3 feet (91.44 centimeters) on both sides and 2 feet (60.96 centimeters) at the foot of the sterile field
      • • Movable equipment zone: 2 feet 6 inches (76.20 centimeters) on the sides and 2 feet (60.96 centimeters) at the foot of the circulation pathway
      • • Anesthesia work zone: 6 × 8 feet (1.83 × 2.44 meters) at the head of the operating table, gurney, or procedural chair
    The sterile field includes the OR table and clearance on each side and at the foot to accommodate personnel.
    The circulation pathway provides space for two people to meet and pass each other without touching either non-sterile surfaces (e.g., walls, people, or equipment) on one side or personnel wearing sterile attire who are standing at the sterile field on the other side. The circulation pathway is intended to provide space for personnel to set up a sterile field prior to the procedure, assist with safe patient evacuation using a stretcher in case of an emergency, pass between the back table and the wall during the procedure, and pass at the head of the patient without interfering with care being provided by the anesthesia care provider(s).
    The movable equipment zone provides space on each side and at the foot of the table to accommodate the minimum equipment for the surgical procedure. In the 255- and 270-square-foot operating rooms, it is assumed there will not be a lot of equipment so the circulation pathway and movable equipment zone are combined.
    The anesthesia work zone is a 6 × 8-foot (1.83 × 2.44-meter) space at the head of the table, but once anesthetic delivery and monitoring have been established, 2 feet (60.96 centimeters) at the top of that zone can be used as part of the circulation pathway.
  2. In determining the size of an operating room, the minimum equipment for the surgical procedures to be performed should be considered. This may include the following:
    • -Anesthesia machine
    • -Anesthesia supply cart
    • -Chair for the anesthesia care provider
    • -Intravenous pole or table
    • -Case cart/equipment delivery system cart
    • -Prep stand
    • -Portable documentation station with chair
    • -Back instrument table
    • -Ring stand
    • -Two trash containers
    • -Soiled linen container
    • -Hazardous waste receptacle
    • -Mayo stand
    • -Kick bucket
    • -Surgical field suction
    • -Image viewers
    • -Sharps disposal receptacle
    When calculating the clear floor area and clearances needed to accommodate the minimum amount of equipment, it was assumed all equipment would fit tightly together; however, this frequently is not possible due to the shape of the equipment so more space may be needed.
  3. The number of required personnel for the procedures to be performed should also be considered in determining operating room size. Required personnel may include a surgeon, scrub nurse/technician, circulating nurse, and anesthesia care provider(s).
A2.1-3.2.3.2 (1) Space requirements for operating rooms for procedures that require additional personnel/large equipment. Operating rooms for surgical procedures that require additional personnel and/or large equipment should be sized to accommodate the personnel and equipment planned to be in the room during procedures, including any additional personnel and equipment that will be needed for emergency rescue. These operating rooms may need to have a clear floor area of 600 to 1,000 square feet (55.74 to 92.9 square meters).
A2.1-3.2.3.2 (1)(c) To allow for an operating room to be used for different procedures in the future, a health care organization may choose to build a larger operating room than needed for the services they are currently providing.
  1. Accommodations for written and/or electronic documentation shall be provided in the operating room.
  2. Where a built-in feature is provided for documentation, it shall allow for direct observation of the patient when in use.
Each operating room shall have access to at least one medical image viewer.
Hand scrub facilities shall be provided in accordance with Section 2.1-3.8.6 (Hand Scrub Facilities).
  1. Surfaces. See Section 2.1-7.2.3 (Surfaces) for requirements.
  2. Building system requirements
    1. HVAC system
      1. See Part 3 (ANSI/ASHRAE/ASHE 170: Ventilation of Health Care Facilities) for ventilation requirements for operating rooms.
      2. Anesthetic gas scavenging system. For operating rooms where general anesthesia is provided, see note m in Table 8.1 (Design Parameters) in ASHRAE/ASHE 170.
    2. Electrical receptacles. See Table 2.1-1 (Electrical Receptacles for Patient Care Areas in Outpatient Facilities) for requirements.
    3. Plumbing systems
      1. See Section 2.1-8.4.2.6 (Drainage systems) for requirements.
      2. Medical gas requirements. See Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities) for requirements.
    4. Communications systems
      1. All operating rooms shall be equipped with an emergency communication system that incorporates push activation of an emergency call switch.
      2. For nurse call device requirements, see Table 2.1-3 (Locations for Nurse Call Devices in Outpatient Facilities).
  • (1)  General
    • (a)  Facilities that have an operating room(s) shall have the support areas in this section.
    • (b)  Sharing of these support areas with other clinical services in the facility shall be permitted.
  • (2) — (7) Reserved
  • (8)  Medication safety zone. See Section 2.1-3.8.8 (Medication Safety Zones) for requirements.
  • (9) — (10) Reserved
  • (11) Clean storage
    • (a)  A storage area for clean/sterile supplies shall be provided.
    • (b)  Facilities with more than one operating room shall have a clean workroom.
  • (12) Soiled holding. A space for holding soiled materials shall be provided that is separate from the clean storage area.
  • (13) — (15) Reserved
  • (16) Sterile processing facilities. Where sterile processing is performed on-site, sterile processing facilities shall be provided in accordance with Section 2.1-4.3.2 (Facilities for On-Site Sterile Processing).
  • (17) Pre- and post-procedure patient care. Where pre- and post-procedure patient care is required to support the procedures performed in the operating room, the requirements in this section shall be met.
    • (a)  Location. Pre- and post-procedure patient care stations(s) shall be permitted to be located in the operating room or in a specifically designated patient care area.
    • (b)  Design requirements. Where pre- and post-procedure patient care stations are located in a specifically designated patient care area, see Section 2.1-3.7 (Pre- and Post-Procedure Patient Care) for requirements.
  • (1) — (3) Reserved
  • (4)  Storage for patients' belongings. Provisions shall be made for securing patients' personal effects during surgery.
Requirements for other types of special patient care rooms are located in the facility chapters.
  1. In facilities that serve patients with known infectious disease, the need for and number of airborne infection isolation rooms shall be determined by an infection control risk assessment (ICRA).
  2. Where an AII room(s) is provided, it shall meet the requirements for the clinical space (e.g., exam room, procedure room) and the requirements in this section.
A2.1-3.3.2.1 For additional information, refer to the Centers for Disease Control and Prevention (CDC) publication "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings" and "Guidelines for Environmental Infection Control in Health-Care Facilities," both available on the CDC website.
  1. Capacity. Each room shall accommodate only one patient.
  2. Hand-washing station. A hand-washing station shall be located in each AII room.
  3. Personal protective equipment (PPE) storage. Provision shall be made for PPE storage at the entrance to the room.
An anteroom is not required; however, where an anteroom is provided, it shall meet the following requirements:
  1. The anteroom shall provide space for persons to don PPE before entering the AII room.
  2. All doors to the anteroom shall have self-closing devices.
  3. The anteroom shall be equipped with at least the following:
    1. Hand-washing station
    2. Storage for unused PPE
    3. Disposal/holding container for used PPE
The requirements in this section are in addition to those in Section 2.1-7.2 (Architectural Details, Surfaces, and Furnishings) that apply to AII rooms.
(1)  Architectural details
(a)  AII room perimeter walls, ceiling, and floor, including penetrations, shall be constructed to prevent air exfiltration; see Section 7.2.1 (AII rooms) in Part 3: ANSI/ASHRAE/ASHE Standard 170.
(b)  Doors
(i)  AII rooms shall have self-closing devices on all room exit doors. Omission of these devices shall be permitted if the alarm required in Section 2.1-3.3.2.5 (Pressure alarm) has an arrangement that allows activation of the audible alarm when the AII room is in use as an isolation room.
(ii)  Edge seals shall be provided along the sides and top of the doorframe for any door into the AII room.
*(iii) Use of bottom edge door sweeps to assist in maintaining negative pressure shall be permitted.
(2)  Furnishings
(a)  Window treatments shall be provided in accordance with Section 2.1-7.2.4.2 (Window treatments in patient care areas) except that fabric drapes and curtains shall not be used.
*(b)  Use of fabric privacy curtains shall be permitted if they are washable.
A2.1-3.3.2.4 (1)(b)(iii) Door sweeps. To support maintenance of negative pressure, the opening under the door should be the minimum required for proper door operation. However, if the AII room is not sealed well and the negative pressure of the room cannot be maintained at negative 0.01 inches of water column (negative 2.5 pascals) without a door sweep, provision of a sweep is necessary.
A2.1-3.3.2.4 (2)(b) Use of a wipeable fabric with a smooth surface is preferable.
A visual or audible alarm that indicates if negative pressure is not maintained in the room shall be provided for the AII room.
A2.1-3.4 Patient experience. Remote communications via electronic equipment, although not a replacement for in-person care, may be offered as a supplement where in-person care is not available or medically necessary. To assist in the adoption of telemedicine and maximize its benefits for elderly patients, those unaccustomed to electronic communication, and those with vision, hearing, or cognitive impairments, care should be given to remove technological barriers and provide telemedicine endpoints that facilitate natural communication for the widest range of participants. Facilities and systems used for telemedicine communications should strive to maintain the level of safety, privacy, quality of care, and patient experience that would be expected for in-person communication.
  1. Services may include one-on-one interactions, consultations with a patient and family members (e.g., pediatric or elderly patients), examinations supported by a telemedicine presenter located with the patient, or specialty services such as dermatology or orthopedics. Each type of service may have specific needs for lighting and space to support the clinical function; for example, evaluation of patient gait requires unobstructed space to walk from one end of the bay, cubicle, or room to the other. Therefore, to achieve a functional design, it is important to know what services will be provided.
  2. The requirements in this section are not intended to apply to virtual visits that do not require a physical examination of the patient or visits that originate from a physician's or patient's home.
A bay, cubicle, or room shall be provided for telemedicine services.
A2.1-3.4.2 Design considerations
  1. Equipment
    • -Camera placement should be set so recipients perceive the exchange as happening eye-to-eye. The discrepancy between gaze angle should be minimal.
    • -Temperature control should be considered based on the amount of electronic equipment that may generate significant amounts of heat.
    • -Depending on the complexity of equipment used, multiple outlets may be required for equipment. Outlets should be located near the unit to avoid wires/cables on the floor.
  2. Architectural details
    • -Doors in view of the main camera should be able to be closed to assure maximum privacy during the telemedicine appointment.
    • -Placement of doors behind the patient should be avoided as this can make patients uncomfortable.
  1. A bay, cubicle, or room where clinical telemedicine services are provided shall meet the requirements of the section of the Guidelines that directly relates to the services provided and the patient population served.
  2. Where patient volume does not justify provision of a dedicated telemedicine room, a telemedicine room shall be permitted to serve other functions such as physician's office, exam room, or conference room.
Where used for examination purposes, the telemedicine bay, cubicle, or room shall be sized to accommodate the following:
  1. An examination table situated within view of the camera
  2. Telemedicine equipment (fixed or mobile)
  3. Peripheral devices
  4. An on-site caregiver or patient presenter
  5. A hand-washing station where hands-on patient examinations are provided
  6. A documentation area
A2.1-3.4.2.2 Sizing considerations
  1. Where a separate camera and microphone are used rather than a computer or other electronic device, the distance between walls will determine the proximity of the camera and microphone to the patient. Use of a small bay, cubicle, or room may force the camera to be located too close to the patient, limiting the view of the clinician presenting the patient for consultation. Therefore, the camera and exam table should be positioned so a presenter using and manipulating telemedicine peripherals can see both the patient and the monitor of images being transmitted to the remote clinician's site.
  2. Stationary cameras should be placed on top of the monitor used for viewing and directed toward the patient to capture the most information possible (i.e., head plus full-body shots). This is easier with dedicated telemedicine carts than with desktop or mobile units.
  3. Where the microphone is not embedded in the device being used (e.g., desktop, laptop, smartphone, or similar device), space for microphones should be placed in front of and close to the individuals speaking in the videoconference, ideally at least 4 feet from the telemedicine workstation to prevent audio feedback.
  4. The bay, cubicle, or room should be large enough for the patient and the patient presenter, if one is present, to move around comfortably. The patient should be able to sit in a chair as well as use the examination table. Where necessary, a fax machine should be directly accessible. A second chair should be available for a family member.
  5. Where the examination includes gait evaluation, the bay, cubicle, or room should provide sufficient space for this activity to be captured by the camera.
  1. The telemedicine bay, cubicle, or room shall provide speech and visual privacy with adjacent spaces based on the bay, cubicle, or room's clinical function, as indicated in Table 1.2-7 (Design Criteria for Speech Privacy for Enclosed Rooms and Open-Plan Spaces).
  2. Space shall permit arrangement of monitors, screens, or other projections of images or data so they are not visible to causal observers outside the telemedicine bay, cubicle, or room.
(1)  Speech intelligibility. Telemedicine rooms shall maintain the minimum sound absorption coefficient for the room's clinical requirement in Table 1.2-4 (Minimum Design Room Sound Absorption Coefficients) or 0.10 (absolute), whichever is greater.
*(2)  Sound isolation. Telemedicine rooms shall achieve the minimum STC rating for the room's clinical requirement in Table 1.2-6 (Design Criteria for Minimum Sound Isolation Performance Between Enclosed Rooms).
(3)  Background noise. Telemedicine bays, cubicles, or rooms shall maintain background noise levels for the room's clinical requirement in Table 1.2-5 (Maximum Design Criteria for Noise in Interior Spaces Caused by Building Systems).
A2.1-3.4.2.4 Acoustic considerations. The acoustic environment should be designed to facilitate speech intelligibility and communication. The telemedicine bay, cubicle, or room should be in a quiet location that minimizes exposure to noise that can be picked up by microphones. Noise sources may include, but are not limited to, open office areas, busy corridors, stairwells, parking lots, waiting rooms or areas, HVAC systems, and toilet rooms. Cooling fans for equipment should be controlled and limited for telemedicine bays, cubicles, or rooms.
A2.1-3.4.2.4 (2) In designing to achieve the minimum STC rating, all portions of the room's envelope should be considered, including walls, floor/ceiling assemblies, doors, glazing, and field conditions that may affect the performance of those elements.
*(1)  The bay, cubicle, or room shall provide the ability for direct frontal lighting.
*(2)  Means for controlling glare from natural and artificial light sources shall be provided.
A2.1-3.4.2.5 (1) Lighting considerations
  1. Direct and indirect lighting should be provided to create images that have even lighting and accurately reproduced colors.
  2. Full-spectrum or warm, white light (3200—4000 K) should be provided.
  3. A minimum light level of 150 fc should be provided.
A2.1-3.4.2.5 (2) Controlling glare
  1. Bays, cubicles, or rooms with windows should have shades or blinds to reduce light and glare, although this may not be enough to achieve acceptable images. In rooms with windows, it should be possible for clinicians and/or patients to avoid sitting in front of a window unless the backlighting can be adequately addressed.
  2. A good source of diffused light is needed in front of the patient shining diagonally toward the patient to reduce shadows that occur on the face if only overhead lighting is used or if there is a light source behind the patient. Spotlights or harsh directional lighting can create unwanted shadows. "Egg-crate" diffusers are not recommended due to "hot spots."
*(1)  Bay, cubicle, or room finishes and colors shall be selected to maintain natural rendition of color and pattern.
*(2)  Backdrop wall color shall have a light reflectance value of 30 to 40 percent.
A2.1-3.4.2.6 (1) Interior surfaces
  1. Light to medium blue or light gray matte finishes are recommended for proper color rendition and to facilitate picture clarity. These shades are preferred because they offer the desired minimal light absorption and light reflectivity. (Although green is the color of choice for a surgical suite because it offers visual comfort when viewing pink and red tissues for a prolonged time, it is not appropriate here.)
  2. Use of this color can be limited to the walls that will be the background for the camera views. This may include more than one wall depending on the configuration of the bay, cubicle, or room.
  3. Screens or curtains may be used to provide the appropriate background color or to hide clutter (e.g., bookshelves, framed pictures with glass).
A2.1-3.4.2.6 (2) Avoiding glare and contrast
  1. A surface finish gloss rating level 1 or 2 (flat finish) should be used rather than gloss level 5 (semi-gloss) or gloss level 6 (gloss finish) to avoid glare and reflections. Reference the Master Painters Institute Gloss and Sheen Standards for latex versus alkyd paint gloss ratings.
  2. Glare and contrast problems in the visual environment may be avoided by specifying the following light reflectance values for surfaces in the telemedicine bay, cubicle, or room:
    • -Ceilings: 80—90 percent
    • -Furniture: 25—45 percent
    • -Flooring: 20—40 percent
Facility identification shall be provided at the site so it appears in the transmitted image unless it is embedded in the telemedicine platform.
A2.1-3.4.2.7 Site identification. Facility identification may be provided through signage, such as a sign with the name of the site in the background, or site identification incorporated into the telemedicine technology platform. Identification can help keep everyone oriented and may be required for reimbursement.
Where portable equipment and peripheral devices are used (e.g., digital camera and task lighting, portable EKG devices, smartphones, roaming robots), secure storage shall be provided.
A2.1-3.4.3 Infection prevention considerations for telemedicine spaces. Telemedicine equipment should be selected and installed to facilitate cleaning and infection prevention practices.
A2.1-3.5 Imaging services. Imaging services commonly include radiography, fluoroscopy, mammography, tomography, computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and other imaging modalities. Of the various imaging modalities used, many are performed for diagnostic purposes by projecting energy through a mass (the patient) and recording the resultant energy characteristics. Some procedures involve various forms of therapeutic interventional imaging or image guidance in conjunction with invasive procedures. Others-such as nuclear imaging-place radioactive substances inside the patient and record metabolic energy emissions. For guidelines on radiosurgery and proton therapy facilities, see Section 2.1-3.6 (Radiation Therapy).
A2.1-3.5.1 Location. Where physical proximity cannot be provided, or where imaging services serve a specific population (e.g., CT scanner located in the emergency department), distributed imaging services may be considered in lieu of physical proximity, but this arrangement should not result in the need for inefficient duplication of staff or equipment. Particular attention should be paid to the management of outpatients for preparation, holding, and observation. Emergency, surgery, cystoscopy, and outpatient clinics should be accessible to imaging services.
  1. Where imaging services are provided in an outpatient facility, facilities for the modalities offered shall meet the requirements in this section.
  2. The requirements in this section shall not apply to imaging services provided in mobile/transportable medical units except as noted in Chapter 2.13, Specific Requirements for Mobile/Transportable Medical Units.
To differentiate the design and construction requirements needed to achieve the environmental controls and other requirements that support the amount of intervention to be provided, imaging rooms shall be classified as described in Table 2.1-5 (Classification of Room Types for Imaging Services).
For imaging services that require radiation protection, a certified radiation physicist or equally qualified expert representing the owner or appropriate state agency shall specify the type, location, and amount of radiation protection to be installed in accordance with the final approved imaging services layout and equipment selections.
(1)  Shielded control alcove or room. Each imaging room containing non-portable radiation-emitting imaging equipment or imaging equipment requiring shielding from external sources of interference shall include a fixed shielded control alcove or control room to minimize radiation exposure of technologists and others. Movable imaging equipment affixed to rails, tracks, or booms shall not be considered portable.
(a)  Space requirements. The control alcove or room shall be, at minimum, sized and configured in compliance with the equipment manufacturer's recommendations for installation, service, and maintenance.
*(b)  A control alcove or room shall be permitted to serve more than one imaging room, provided the manufacturer's recommendations for installation, service, and maintenance are accommodated for all rooms served.
*(c)  Shielded view window. The control alcove or room shall include a shielded view window designed to provide a full view of the examination/procedure table and the patient at all times, including a full view of the patient during imaging activities (e.g., when the table is tilted or the chest x-ray is in use). If a direct line of sight cannot be accommodated due to functional requirements, use of closed-circuit video monitoring shall be permitted.
(d)  The control room shall be physically separated from the Class 2 or Class 3 imaging room with walls and a door.
(e)  Where an imaging room requires positive (or negative) pressure, a door shall be provided between the control room and the imaging room.
*(f)  Omission of the control alcove or room shall be permitted in electrophysiology labs if approved by a certified radiation physicist and provisions are made for individual staff radiation shielding.
*(2)  Radiation protection requirements shall be incorporated into the specifications and the building plans.
A2.1-3.5.1.3 Shielding for an ionizing radiation enclosure may also be subject to acceptance testing, which should be performed by the certified radiation physicist or qualified expert as specified in applicable local, state, or federal requirements.
A2.1-3.5.1.3 (1)(b) Shared control rooms are sometimes not desirable, especially in Class 2 and Class 3 imaging rooms, due to excessive noise and possible infection prevention issues.
A2.1-3.5.1.3 (1)(c) Shielded view window. A certified radiation physicist or other qualified expert representing the owner or appropriate state agency should determine the minimum distance to be provided between the outside edge of the shielded view window and the outside partition edge to prevent exposure of technologists or others positioned near the outside edge of the window.
A2.1-3.5.1.3 (1)(f) Provisions for individual staff radiation shielding may include mobile lead barriers or leaded apparel.
A2.1-3.5.1.3 (2) Data required by the physicist may include the following:
  1. Make, model, and placement of imaging equipment
  2. Room size and configuration (including horizontal and vertical dimensions)
  3. Anticipated frequency and duration of radiation emissions
  4. Description of adjacent occupants (above, below, and horizontally)
  5. Room construction materials and assemblies
  1. The requirements in this section shall apply to imaging rooms for all modalities except where indicated.
  2. Where an imaging room will be used for Class 1 and Class 2 procedures, the more stringent requirements for the higher class room shall be followed.
  3. Where an imaging room intended for Class 3 procedures is provided, it shall meet the requirements for the applicable imaging modality and the requirements for an operating room in Section 2.1-3.2.3 (Operating Rooms), except for Section 2.1-3.2.3.2 (Space requirements).
Space shall be provided to accommodate the equipment and staff needed for planned imaging services.
  1. Imaging rooms shall be sized and configured, at minimum, to comply with the manufacturer's recommendations for installation, service, and maintenance.
  2. Imaging rooms shall be sized to provide the following minimum clearances:
    1. 4 feet (122 centimeters) on all circulating sides of the patient table/bed/couch, gantry, or assembly
    2. Other clearances in accordance with clinical needs (e.g., medical gas service, anesthesia cart, clinical staff)
A2.1-3.5.2.2 Space layouts should be developed to meet the minimum requirements in the manufacturer's technical specifications because area requirements may vary from machine to machine. However, manufacturers' recommendations should not be used as the sole determinant for room size as they may not take into consideration the clinical needs at a particular facility. As well, because technology changes and siting requirements frequently vary from manufacturer to manufacturer, rooms should be sized larger than manufacturer's minimum technical specifications to allow for upgrading of equipment over time.
Consideration should also be given for the space needs of other equipment (e.g., physiological monitoring or dye injectors).
Hand-washing stations and hand scrub facilities shall comply with the requirements in Section 2.1-3.8.7 (Hand-Washing Station) and Section 2.1-3.8.6 (Hand Scrub Facilities).
  1. A hand-washing station shall be provided in Class 1 imaging rooms unless specified otherwise for a specific imaging modality.
  2. A hand-washing station or hand scrub facilities shall be provided for Class 2 imaging rooms.
    1. Where a hand-washing station is provided, it shall be directly accessible to the Class 2 imaging room.
    2. Where hand scrub facilities are provided, a hand scrub position shall be directly outside the entrance to the Class 2 imaging room.
  3. Hand scrub facilities shall be provided directly outside the entrance to Class 3 imaging rooms.
The following shall apply to all imaging rooms, with noted exceptions:
(1)  Architectural details
(a)  Floor
(i)  Class 2 and Class 3 imaging rooms shall meet the flooring requirements in Section 2.1-7.2.3.1 (6) (Floor and wall base assemblies).
(ii) Floor finishes shall be selected to conform to imaging equipment technical requirements (e.g., electrostatic dissipation), rolling resistance to carts and tables, and service limitations (e.g., no powered floor cleaners in an MRI scanner room).
(b)  Ceiling
(i)  Where only general diagnostic procedures are performed, use of a lay-in ceiling shall be permitted.
(ii) Class 2 imaging rooms shall be provided with ceiling assemblies that meet the requirements in Section 2.1-7.2.3.3 (2) (Ceilings-Semi-restricted areas).
(iii) Class 3 imaging rooms shall be provided with ceiling assemblies that meet the requirements in Section 2.1-7.2.3.3 (3) (Ceilings-Restricted areas).
(c)  Door openings. Imaging rooms shall have entrance door openings that comply with Section 2.1-7.2.2.3 (Doors and door hardware).
*(d) Structural support. The floor and, if applicable, ceiling structures in imaging rooms shall be designed to support the weight of the imaging equipment as well as other fixed ancillary equipment (e.g., lights, service columns) and movable ancillary equipment.
*(e) Protection from vibration and other disturbances. Imaging room(s) shall be protected from environmental vibrations and other disturbances in accordance with the imaging equipment manufacturer's technical specifications.
(2)  Building system components
(a)  Electrical receptacles. For requirements, see Table 2.1-1 (Electrical Receptacles for Patient Care Areas in Outpatient Facilities).
(b)  Medical gas systems. For requirements, see Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities).
(c)  Call systems. For requirements, see Table 2.1-3 (Locations for Nurse Call Devices in Outpatient Facilities).
A2.1-3.5.2.4 (1)(d) Structural support. The design team should consider the long-term flexibility of the imaging rooms when designing equipment supports. In lieu of customized supports for each suspended item, a regularly spaced grid of overhead structural members may enable rapid changes to the room, such as repositioning surgical lights and service columns, and facilitate future equipment replacement.
A2.1-3.5.2.4 (1)(e) Protection from environmental disruptions
  1. Many imaging systems are highly sensitive to vibration, electromagnetic interference, and other forces that arise from adjacent equipment movement, electrical rooms, and unassociated building equipment. These forces can result in serious degradation of images. Project teams should consult with equipment manufacturers to determine whether site readiness testing is required prior to equipment installation and to strategize about control mechanisms to mitigate such forces.
  2. Many imaging systems are cooled via closed liquid-based cooling loops that must necessarily cross into imaging rooms. Such cooling loops require protective means to reduce the possibility of water leakage into ceiling or wall cavities surrounding invasive fluoroscopy rooms. The design team should consider double-jacketing horizontal or vertical cooling lines and installing protective drip pans below lines in ceiling cavities.
Where a system component room is provided, it shall meet the requirements in this section.
(1)  Location
*(a)   For Class 2 and Class 3 imaging rooms, the system component room shall not open into the imaging room or any restricted space.
(b)  A system component room shall be permitted to be shared among multiple imaging rooms provided the equipment manufacturer(s) permit such sharing.
*(2)  Space requirements. The system component room shall be sized to accommodate the following as indicated by the imaging equipment manufacturer(s), including the clear floor area:
(a)  Transformers
(b)  Power distribution equipment
(c)  Power conditioning/UPS equipment
(d)  Computers
(e)  Associated electronics and electrical gear
A2.1-3.5.2.5 Purposes for a system component room. Many imaging modalities require the use of electronics components that may be required or preferred to be located in a room unto themselves for heat load, infection control, noise, or serviceability reasons (or combinations thereof).
A2.1-3.5.2.5 (1)(a) System component room maintenance access. If equipment requires technicians to view the imaging equipment during maintenance, a window between the system component room and the imaging room or a closed-circuit video camera can be used to provide this access.
A2.1-3.5.2.5 (2) System component room space requirements. The size of the system component room should be based on the equipment manufacturer's space requirements for imaging system components as well as on the amount of additional gear that may be required. The project team should consider space needs for electrical transformers and panels, supplemental cooling units, heat exchangers, pumps, and other gear that may not be readily evident from manufacturer-provided installation documents. Many of these items need clear floor space on one or more sides to allow for service access.
Where two or more individual imaging or therapy modalities are integrated into one imaging device (e.g., PET/CT, SPECT/CT or PET/MRI), the minimum design requirements for that room shall include the design criteria for each individual contributing modality.
A2.1-3.5.2.6 Multiple-modality devices. Multiple-modality devices include dual-diagnostic devices such as SPECT/CT or PET/MRI, but may also include unions of diagnostic and therapeutic technologies, such as MRI/Linac.
Nuclear imaging exquisitely depicts metabolic activity but does not necessarily clearly convey anatomic structure. Radiographic images typically clearly convey anatomic structure, but not necessarily metabolic or functional information. Magnetic resonance exquisitely conveys anatomic structure. Certain types of magnetic resonance imaging, such as magnetic resonance angiography (MRA), also convey metabolic activity clearly. Multiple-modality devices make it possible to achieve complementary imaging results from one procedure.
Although such multiple-modality devices are sometimes referred to as "hybrid" machines, this term is not used here to avoid confusing rooms where these devices are used with "hybrid operating rooms." A hybrid operating room typically integrates any one of (or several) image-guided modalities (e.g., fluoroscopy, magnetic resonance, CT, PET, etc.) with surgical procedures.
Both multiple-modality devices and hybrid operating rooms exist in numerous configurations involving a variety of imaging techniques. It is anticipated that the diversity of imaging modalities used in these spaces will only increase in the future, and it is important to recognize that the design requirements of these spaces must respond to the myriad-and often complex-physical requirements of each modality incorporated in the space.
A2.1-3.5.3 Interventional CT scan procedures to be performed in a facility should be identified in the functional program. Guidelines requirements related to those procedures should be applied if the intervention is performed in the CT scanner room.
  1. The CT scanner room shall meet the requirements in sections 2.1-3.5.1 (Imaging Services-General) and 2.1-3.5.2 (Imaging Rooms) as amended in this section.
  2. A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the CT scanner room.
A control room or alcove that meets the requirements in Section 2.1-3.5.1.3 (1) (Shielded control alcove or room) shall be provided.
Where provided, a system component room shall meet the requirements in Section 2.1-3.5.2.5 (System component room).
  1. All imaging rooms where radiography services are performed shall meet the requirements in Section 2.1-3.5.1 (Imaging Services-General).
  2. Room design and equipment siting shall accommodate the manufacturer's operational, service, and safety clearances for the imaging equipment used.
  3. Shielded control alcove
    1. See Section 2.1-3.5.1.3 (1) (Shielded control alcove or room) for requirements.
    2. For mammography machines with built-in shielding for the operator, omission of a shielded control alcove shall be permitted when approved by the certified radiation physicist or authority having jurisdiction.
  1. Radiography rooms shall meet the requirements in Section 2.1-3.5.4.1 (Radiography Facilities-General) and Section 2.1-3.5.2 (Imaging Rooms).
  2. A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the radiography room.
Fluoroscopy rooms shall meet the requirements in Section 2.1-3.5.2 (Imaging Rooms) as amended in this section.
  1. A separate toilet room with hand-washing station shall be directly accessible from each dedicated Class 1 fluoroscopy room or combination radiography/fluoroscopy room. Patients shall be able to leave the toilet room without reentering the fluoroscopy room.
  2. Location of Class 2 and Class 3 fluoroscopy rooms used for different clinical applications in the same area or suite of rooms shall be permitted. These rooms shall be permitted to share common support areas.
  3. Hand-washing station or hand scrub facilities. Fluoroscopy rooms shall meet the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities).
  4. Control room or alcove for fluoroscopy
    1. For Class 1 and Class 2 fluoroscopy rooms, a control room or alcove that meets the requirements in Section 2.1-3.5.1.3 (1) (Shielded control alcove or room) shall be provided.
    2. For Class 3 fluoroscopy rooms, a control room that meets the requirements in Section 2.1-3.5.1.3 (1) (Shielded control alcove or room) shall be provided.
    3. The control room door in Section 2.1-3.5.1.3 (l)(d) shall not be required where the control room serves only one fluoroscopy room that meets the requirements of a Class 2 or Class 3 imaging room and the control room is built, maintained, and controlled the same as a Class 2 or Class 3 imaging room.
Mammography rooms shall meet the requirements in Section 2.1-3.5.4.1 (Radiography Facilities-General) and Section 2.1-3.5.2 (Imaging Rooms) as amended in this section.
  1. Mammography rooms shall be sized to provide the following minimum clearances:
    1. 3 feet on all circulating sides of the patient position
    2. Other clearances in accordance with clinical needs
  2. Visual privacy of patients shall be provided. Views into the mammography room by the public or other patients shall be prevented when the room is in use.
  3. A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the mammography room.
  4. Where patients do not change in the mammography room, changing room(s) for mammography patients shall be immediately accessible to the waiting area and imaging room(s).
    1. Changing room(s) shall comply with the requirements of Section 2.1-3.5.10.3 (Patient changing rooms).
    2. Combination of mammography changing room(s) with changing areas for other imaging services shall be permitted.
A2.1-3.5.4.4 Mammography room. Where needle localization procedures are performed, a discreet patient route of travel (i.e., one that does not pass through public circulation routes) should be provided from the mammography room to a biopsy procedure room.
(1)  Suites for MRI equipment shall conform to the four-zone screening and access control protocols identified in the current edition of the American College of Radiology's "ACR Guidance Document on MR Safe Practices."
(2)  MRI suites as well as spaces around, above, and below (as applicable) shall adhere to International Electrotechnical Commission (IEC) Standard 60601-2-33: Medical electrical equipment - Part 2-33: Particular requirements for the basic safety and essential performance of magnetic resonance equipment for medical diagnosis requirements established to prevent unscreened individuals from entering the 5-gauss (0.5 millitesla) volume around the MRI equipment and to minimize electromagnetic or radiofrequency interference to, or from, other equipment.
(3)  In addition to the clinical and support areas in this section, the following shall be provided in the MRI suite:
(a)  Space for patient interviews and clinical screening
(b)  Space for physical screening
(c)  Ferromagnetic (only) detection and warning systems
(d)  Access control
(e)  Space to accommodate site-specific clinical and operational requirements such as image-guided procedures, emergent imaging, or general anesthesia support
(f)  Space for containment of non-MRI-safe objects outside restricted MRI safety zones
(g)  Space for storage (patient lockers) of patient belongings and non-MRI-safe items
*(4)  Any area in which the magnetic field strength is equal to or greater than 5 gauss (0.5 millitesla) shall be physically restricted by the use of key locks or pass-key locking systems.
A2.1-3.5.5.1 (4) A risk of injury or death is posed by the penetration of areas in which the magnetic field strength is equal to or greater than 5 gauss by unscreened persons or ferromagnetic objects or equipment.
*(1)  MRI scanner rooms shall meet the requirements in sections 2.1-3.5.1 (Imaging Services-General) and 2.1-3.5.2 (Imaging Rooms) as amended in this section.
(2)  Hand-washing station
(a)  A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided.
(b)  Location of the hand-washing station directly outside the entrance to the MRI scanner room shall be permitted.
A2.1-3.5.5.2 (1) If anesthesia support is anticipated, additional space, electrical outlets, and gas lines may be required.
A system for cryogen venting, emergency exhaust, and passive pressure relief shall be provided in accordance with the equipment manufacturer's technical specifications.
A2.1-3.5.5.3 Cryogen venting
  1. To protect occupants in the event of a cryogen escape, an insulated cryogen quench exhaust pipe as well as room exhaust and pressure equalization should be provided where superconducting MRI scanners are installed.
  2. Cryogen venting points of discharge should be clearly marked and shielded from staff and maintenance personnel areas and substantially removed from all public and patient routes of travel.
  3. Cryogen venting points of discharge should have minimum clearances from air intakes, operable windows, or doors as defined by the MRI system manufacturer.
  4. Cryogen venting points of discharge should be designed with weather head sufficient to protect against the ingress of horizontally driven rain.
  5. Accessible areas around cryogen vent discharge should be marked to indicate the safety exclusion zone in accordance with MRI equipment manufacturer standards.
A control room that meets the requirements in Section 2.1-3.5.1.3 (1) (Shielded control alcove or room) shall be provided as amended in this section.
  1. The operator's console shall be positioned so the operator has a full view of the principal approach and entrance to the MRI scanner room.
  2. Where there is an outward-swinging door, in the open position the door shall not obstruct the view of the entry opening from the operator's console.
  1. The control vestibule shall be located outside the MRI scanner room so that patients, health care personnel, and other employees must pass through it before entering the MRI scanner room.
  2. The control vestibule shall be permitted to be either a part of the MRI control room or directly visible from the control room.
An area adjacent to the MRI room shall be provided for patient code treatment/resuscitation.
A2.1-3.5.5.6 The patient treatment/resuscitation area should be located in the MRI suite as specified in the American College of Radiology's "ACR Guidance Document on MR Safe Practices."
A system component room that meets the requirements in Section 2.1-3.5.2.5 (System component room) shall be provided.
*(1)  Power conditioning and/or uninterruptible power supplies shall be provided as indicated by the MRI manufacturer's power requirements and specific facility conditions.
(2)  Radiofrequency (RF) shielding shall be provided for clinical MRI installations to attenuate stray radio frequencies that could interfere with the MRI imaging process.
*(3)  At sites where magnetic field hazards or interferences are not adequately controlled through facility planning (i.e., by physical distance), the need for magnetic shielding shall be assessed by a certified physicist experienced in magnetic shielding design or an equally qualified expert.
A2.1-3.5.5.8 (1) Power conditioning and voltage regulation equipment as well as direct current (DC) may be required.
A2.1-3.5.5.8 (3) Magnetic shielding can often be avoided in new construction when suite design and planning are employed to mitigate magnetic field hazards.
Magnetic shielding may be required to restrict the magnetic field plot. The area around, above, and below the MRI suite should be reviewed and evaluated for the following:
-Possible occupancy by person(s) who could have pacemakers or other implants
-Equipment that can be disrupted by a magnetic field. Examples include but are not limited to computers, CT scanners, and nuclear cameras.
After reviewing and evaluating the surrounding space, appropriate magnetic shielding may be required based on the type of MRI scanner to be installed.
(1)  General
(a)  Ferromagnetic materials that may become detached or otherwise interfere with the operation of the MRI scanner shall not be used in MRI scanner rooms.
*(b)  The MRI scanner room shall be located and/or shielded to avoid electromagnetic interference from elevators or other electromagnetic equipment.
*(2)  Architectural details
(a)  The floor structure shall be designed to support the weight of MRI scanner equipment, minimize disturbance to the MRI magnetic field, and mitigate disruptive environmental vibrations.
(b)  MRI rooms shall be marked with a lighted sign with a red light to indicate that the magnet is always on.
(c)  Acoustic control shall be provided to mitigate the noise emitted by the MRI scanner. For requirements, see Table 1.2-6 (Design Criteria for Minimum Sound Isolation Performance Between Enclosed Rooms).
A2.1-3.5.5.9 (1)(b) The location, quantity, and distance of structural steel should also be considered in locating the MRI unit.
A2.1-3.5.5.9 (2) Architectural details for the MRI scanner room
  1. Radiofrequency (RF) and magnetic shielding. All doors, windows, and penetrations into the RF-shielded enclosure should be RF-shielded. Therefore, wall, floor, and ceiling assemblies should accommodate the installation of RF-shielded assemblies.
    In addition, individual sites may require magnetic shielding to restrict magnetic interference. Floor and ceiling assemblies as well as the building structure should accommodate magnetic shielding. Note: Floor assemblies are required to minimize disturbance to the MRI scanner's magnetic field; see Section 2.1-3.5.5.9 (2)(a) (The floor structure...).
    Space adequate to accommodate the manufacturer's shielding requirements and ground isolation cavities should be allocated between the inside finished face of the MRI scanner room and the outside face of the scanner room "parent wall."
    Penetrations through RF shielding should include a penetration panel and/or wave guides to assure proper performance of the RF enclosure. Wall, floor, and ceiling construction should prevent moisture from degrading or compromising the integrity of the RF shield.
  2. Access for delivery and removal of scanner. Provision of a knock-out panel or roof hatch is recommended for delivery and removal of the MRI scanner as MRI scanners are typically too large to fit through standard door openings.
  3. Surfaces, fixtures and equipment. The dangers of magnetic fields make servicing surfaces, fixtures, and equipment inside the MRI scanner room potentially hazardous. Surfaces, fixtures, and equipment should be selected to minimize the need for maintenance and servicing.
    Facilities may wish to use surfaces or markings to identify the spatial extent of the critical magnetic field strengths surrounding the MRI scanner, including the 5-gauss exclusion zone or other magnetic field strength values that may impair the operation of equipment such as ventilators, pumps, or anesthesia machines.
Ultrasound rooms shall meet the requirements in Section 2.1-3.5.1 (Imaging Services-General) and Section 2.1-3.5.2 (Imaging Rooms) as amended in this section.
  1. Clearances. Ultrasound rooms shall be sized to provide the following minimum clearances:
    1. 3 feet on all circulating sides of the patient table or procedural chair
    2. Other clearances in accordance with clinical needs
  2. Hand-washing station. A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the imaging room.
See Section 2.1-3.5.10.2 (2) (Toilet rooms for imaging rooms) for requirements.
A2.1-3.5.7 The services included in this section are nuclear-enabled diagnostic imaging modalities conducted using low-level radioactive materials that are typically injected into or ingested by the patient. Sometime later, the radioactive emission and uptake of those substances by various structures and/or organs is measured by radiation detectors integral to various types of nuclear imaging devices.
*(1)  Application. Where nuclear imaging services are offered, space to support those services shall be provided in accordance with the requirements in this section.
(2)  Nuclear imaging room. Nuclear imaging rooms shall meet the requirements in Section 2.1-3.5.2 (Imaging Rooms).
(3)  Exercise area or room. Where patients are required to exercise before imaging is conducted, space shall be provided for the following in the imaging room or in a separate room directly accessible to the imaging room:
(a)  Exercise equipment (e.g., stationary bicycle, treadmill)
(b)  Staff work space
(4)  Hand-washing stations. Hand-washing stations shall be provided throughout the nuclear imaging suite at location(s) of patient contact and at locations where radiopharmaceutical materials are handled, prepared, or disposed of. See sections on specific nuclear imaging modalities for additional requirements.
*(5)  Nuclear imaging dose administration area. A dose administration area shall be provided.
(a)  The dose administration area shall be located near the preparation area.
(b)  Because several hours may elapse before a dose takes effect, the area shall provide for visual privacy from other areas.
(c)  Combination of this area with a pre-procedure patient care area(s) as described in Section 2.1-3.7 (Pre- and Post-Procedure Patient Care) shall be permitted provided there is visual privacy between the areas.
(d)  For PET services, combination of this area with a patient uptake room as described in Section 2.1-3.5.7.3 (6) (Patient uptake/cool-down room) shall be permitted.
(6)  Surfaces. Surfaces throughout the nuclear imaging suite shall be constructed of cleanable, nonporous materials that can be decontaminated.
A2.1-3.5.7.1 (1) Space requirements will vary depending on the specific requirements of each nuclear imaging device. Common to all nuclear imaging services, however, is the need for:
  1. Secure storage of radioactive materials in accordance with applicable state and federal law
  2. Identification of controlled and non-controlled zones. Where radio-active pharmaceuticals are used, controlled zones are restricted (e.g., no food is permitted in controlled zones).
A2.1-3.5.7.1 (5) Dose administration area. Because patients in this area may be held for long periods, the design of the area should incorporate such features as comfortable seating, varied lighting, an entertainment center, music headphones, and availability of reading materials.
*(1)  Scintigraphy rooms shall meet the requirements in sections 2.1-3.5.1 (Imaging Services-General) and 2.1-3.5.2 (Imaging Rooms) as amended in this section.
(2)  Hand-washing station. A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the scintigraphy room.
A2.1-3.5.7.2 Radiation protection for scintigraphy facilities. Scintigraphy/gamma camera services typically use lower-energy radiopharmaceuticals than PET services, reducing-but not eliminating-the infrastructure necessary for radiation protection. Most commonly used for cardiac imaging, new gamma-specific clinical applications (e.g., gamma-specific breast imaging) increase the range of devices and settings that may be called upon to support these services.
A2.1-3.5.7.2 (1) Control room. Due to the comparatively low energy of the most common gamma-specific radiopharmaceuticals, separate shielded control rooms are not typically required for scintigraphy rooms.
*(1)  PET suite configuration
(a)  PET suites shall be designed and positioned in the facility to restrict incidental exposure to ionizing radiation sources by persons not immediately involved in the PET examination.
(b)  A certified radiation physicist or other qualified person shall determine if, and to what extent, radiation shielding is required at radiopharmacy, hot lab, scanner, patient holding, and other spaces.
(2)  PET scanner room
(a)  PET scanner rooms shall meet the requirements in sections 2.1-3.5.1 (Imaging Services-General) and 2.1-3.5.2 (Imaging Rooms) as amended in this section.
(b)  A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the PET scanner room.
(3)  Control room
(a)  A control room that meets the requirements in Section 2.1-3.5.1.3 (1) (Shielded control alcove or room) and is designed to accommodate the controls for the equipment shall be provided.
(b)  A control room shall be permitted to serve more than one PET scanner room.
(4)  System component room. Where a system component room is provided, it shall meet the requirements in Section 2.1-3.5.2.5 (System component room).
(5)  Cyclotron room. Where radiopharmaceuticals are prepared on-site, a cyclotron shall be provided. A cyclotron shall not be required when radiopharmaceuticals are provided by commercial sources.
(a)  Where provided, cyclotron facilities shall be located in access-restricted areas in accordance with applicable state and federal laws.
(b)  Shielding requirements for cyclotron facilities shall be coordinated between the equipment manufacturer and a reviewing medical physicist.
(c)  A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the cyclotron room.
*(6)  Patient uptake/cool-down room. A shielded room(s) shall be provided for patient uptake/cool-down.
(a)  Uptake rooms shall be provided as appropriate to the examinations and radiopharmaceuticals used for the PET service.
(b)  Uptake rooms shall be configured and appointed to minimize patient movement during the radiopharmaceutical uptake period.
*(c) A toilet room with a hand-washing station and a dedicated "hot" toilet to accommodate radioactive waste shall be directly accessible or adjacent to the uptake/cool-down room.
A2.1-3.5.7.3 Positron emission tomography (PET) services involve imaging of patients who have ingested, inhaled, or been injected with a radioactive material. In contrast to x-ray-based studies or procedures, the PET scanner itself does not emit ionizing radiation. Radiation protection in the design of PET facilities is centered on requirements for radiopharmaceutical storage, transport, dosing, administration, duration within the patient, excretions from the patient, and incidental contamination of materials.
A2.1-3.5.7.3 (1) PET suite configuration
  1. Radiation shielding. PET scanners and other nuclear imaging detectors can be adversely affected by the nearby presence and/or movement of patients who have received internally administered radioactive substances. Therefore, radiation shielding is sometimes recommended to prevent inaccurate detector readings, in addition to radiation shielding for human exposure control.
  2. Sound and light abatement. Patients who have been administered radioactive uptake substances prior to their examination may be adversely affected by ambient noise and/or light. Therefore, sound and light abatement is recommended for holding areas for these patients.
  3. Segregated flow for radioactive substances. In facilities where different radioactive substances are administered for PET and non-PET nuclear imaging examinations, consideration should be given to segregating the flow of these radioactive materials.
A2.1-3.5.7.3 (6) Patient uptake/cool-down room. Uptake rooms may also serve as cool-down rooms for patients who, post-examination, retain sufficient radiopharmaceuticals that it is inadvisable for them to be in close proximity to others.
A2.1-3.5.7.3 (6)(c) Toilet room. The intent of the Guidelines is to have a toilet room physically attached to the patient uptake room so a patient with a bad reaction to the preparation can quickly access a dedicated toilet. As well, patients may need access to a toilet room before entering the scanner room.
  1. SPECT rooms shall meet the requirements in sections 2.1-3.5.1 (Imaging Services-General) and 2.1-3.5.2 (Imaging Rooms).
  2. A hand-washing station that meets the requirements in Section 2.1-3.5.2.3 (Hand-washing station or hand scrub facilities) shall be provided in the SPECT room.
Sharing of these support areas with other clinical services in the same facility shall be permitted.
A reception area with control desk shall be provided.
Documentation space that meets the requirements in Section 2.1-3.8.3 (Documentation Area) shall be provided for staff.
An area shall be provided for consultation with patients or the referring clinician, including remote consultation with referring clinicians. See Section 2.1-3.4 (Accommodations for Telemedicine Services) for more information on spaces for remote consultation.
Where medications are administered as part of the imaging services provided, the following requirements shall be met:
  1. A medication safety zone as described in Section 2.1-3.8.8 (Medication Safety Zones) shall be immediately accessible from pre- and post-procedure patient care areas.
  2. Provision shall be made for locked storage of medications.
  1. Storage for clean supplies and linens that meets the requirements in Section 2.1-3.8.11 (Clean Workroom or Clean Supply Room) shall be readily accessible to imaging rooms.
  2. This storage shall be permitted to be shared with other clinical services in the same facility.
(1)  A soiled workroom or soiled holding room shall be provided in accordance with Section 2.1-3.8.12 (Soiled Workroom or Soiled Holding Room).
(2)  Contaminated (hot) soiled holding
*(a) Where nuclear imaging services are offered and a medical physicist has determined it is necessary, a contaminated soiled holding area that is separate from other waste holding areas shall be provided in the soiled workroom or soiled holding room.
(b)  Radiation, occupational, and environmental protections for contaminated holding area(s) shall be provided as defined by a medical physicist.
A2.1-3.5.8.12 (2)(a) Soiled materials from nuclear imaging patients may remain modestly radioactive for a period following patient use. To minimize incidental exposure to ionizing radiation by persons providing environmental services in nuclear imaging areas, the contaminated soiled holding area is operationally integrated.
(1) — (3) Reserved
(4)  Clean linen storage. A storage area for clean linen shall be provided.
  1. An environmental services room with immediate access to the imaging suite shall be provided in accordance with Section 2.1-5.3.1 (Environmental Services Room).
  2. Sharing of the environmental services room with other clinical services shall be permitted.
(1)  For Class 1 imaging rooms, a minimum of one patient care station shall be provided for every three Class 1 imaging rooms or fraction thereof where patients receive point-of-care lab work or injection preparation with non-radiopharmaceutical contrast agents.
*(2)  For Class 2 and Class 3 imaging rooms, pre- and post-procedure patient care area(s) shall be provided in accordance with Section 2.1-3.7 (Pre- and Post-Procedure Patient Care).
(3)  Where surgery facilities are adjacent to imaging facilities, pre- and post-procedure patient care areas shall be permitted to be shared between imaging and surgical services.
A2.1-3.5.8.15 (2) More patient care stations may be needed for imaging rooms where Class 2 and Class 3 imaging procedures take place.
  1. Where contrast media are prepared in the imaging department, this area shall include:
    1. Sink
    2. Counter
    3. Storage to accommodate preparation of contrast media
  2. Where prepared media are used, omission of the sink and counter shall be permitted.
  3. One contrast media preparation area shall be permitted to serve multiple imaging rooms.
  1. Space shall be provided for a digital image management system to be used for image acquisition and transmission.
  2. Location of the image management system off-site shall be permitted.
Space shall be provided to accommodate equipment for image interpretation or "reading" of medical images.
  1. Remote location of image interpretation/reading areas shall be permitted, provided radiologists are immediately available when interventional imaging procedures are performed.
  2. Where provided on-site, image interpretation/reading areas shall include the following:
    1. Lighting
      1. Adjustable ambient lighting with minimal glare projected onto computer monitors
      2. A higher level of illumination for room maintenance (that can be activated separate from ambient reading lighting)
      3. Workstation task lighting for writing or reading hard copy
    2. Acoustic control. Where multiple radiologists interpret images in a contiguous space, materials, finishes, and sound masking that together provide acoustic control to minimize disruption from conversational speaking, dictation, and surrounding noise shall be specified.
A2.1-3.5.8.18 Image interpretation/reading rooms
  1. Computer systems and monitors appropriate for diagnostic-quality interpretation of images, associated patient medical records, and other relevant information found on the radiology information system (RIS) should be provided.
  2. Ergonomically adjustable work surface(s), monitor heights and angles, and chair(s) should be provided in quantities indicated by the services provided and staffing levels.
Where cleaning and high-level disinfection of ultrasound probes is performed in a dedicated room or area, the following requirements shall be met.
(1)  Where an ultrasound probe processing room is provided, it shall meet the following requirements:
(a)  The processing room shall be permitted to serve multiple rooms where ultrasound exams are performed.
(b)  The size of the processing room shall be dictated by the equipment used and the number of probes to be processed.
(c)  The processing room shall allow for the flow of ultrasound probes from the decontamination area to a clean area and then to storage.
(d)  The decontamination area shall be equipped with the following:
(i)  Work counter
(ii) Instrument-washing sink appropriate to the method of decontamination used
(iii) Hand-washing station
(iv)  Space and utility connections to support the high-level disinfection process and equipment used
*(2)  Where ultrasound probes are processed at the point of use or in a separate room or area using a self-contained, automated high-level disinfection unit specifically designed for ultrasound probes:
(a)  Space for the device with access to an electrical receptacle shall be provided.
(b)  Access to a soiled workroom with an instrument-washing sink shall be provided in the same clinical area to support probe decontamination when necessary.
*(3)  Clean ultrasound probe storage. Storage for clean ultrasound probes shall be provided.
A2.1-3.5.8.19 Processing ultrasound probes in a soiled workroom. Some organizations process endocavitary ultrasound probes in a soiled workroom; see Section 2.1-3.8.12 (Soiled Workroom or Soiled Holding Room) for general requirements for a soiled workroom. For soiled workrooms where ultrasound probe or other semi-critical instrument decontamination is performed, an instrument-washing sink would be required.
A2.1-3.5.8.19 (2) The device mentioned in this paragraph is intended to be a unit that does not require plumbing or special ventilation and has been approved solely for the disinfection of ultrasound probes.
A2.1-3.5.8.19 (3) Ultrasound probe storage. Storage for clean probes may be provided in a closed cabinet, or probes may be covered and stored in the imaging room.
Where a centralized computer area is provided, it shall be a separate room with access terminals available in the imaging rooms.
Where radiopharmaceutical preparation is performed on-site, an area to house a radiopharmacy shall be provided with appropriate shielding.
*(1)  Space requirements
(a)  Space shall be provided for dose calibration, quality assurance, and record-keeping activities.
(b)  Space shall be provided for storage of radionuclides, chemicals for preparation, dose calibrators, and records.
(2)  Surfaces. Floors and walls shall be constructed of easily decontaminated materials.
(3)  HVAC system. Hoods for pharmaceutical preparation shall meet applicable standards.
A2.1-3.5.8.21 Radiation protection for the radiopharmacy. This area may require shielding to protect other portions of the facility.
A2.1-3.5.8.21 (1) Radiopharmacy space requirements. If prepared materials are used, the storage and calculation space needed may be considerably smaller than for on-site preparation.
Where scintigraphy, PET, and SPECT services are provided, a securable area or room(s) shall be provided in which radiopharmaceuticals can be safely stored and doses can be calculated and prepared.
  1. A single hot lab shall be permitted to serve multiple nuclear imaging scanners.
  2. The hot lab shall be shielded according to the manufacturer's technical specifications.
  3. The hot lab shall include the following:
    1. Source storage area
    2. Dose storage area
    3. Storage area for syringe shields
    4. Emergency eyewash and/or shower
The following spaces shall be provided:
  1. A staff lounge shall be readily accessible to the imaging facilities. This shall be permitted to be shared with other clinical services.
  2. Provisions shall be made for securing staff belongings, but location of these provisions outside the staff lounge shall be permitted.
  1. A staff toilet room(s) shall be readily accessible to the staff lounge.
  2. In suites of three or more imaging rooms, staff toilets shall be immediately accessible to the imaging suite.
For Class 2 and 3 imaging rooms, a staff changing area that meets the requirements in Section 2.1-3.9.4 (Staff Changing Area) shall be provided. This space shall be permitted to be shared with surgery services.
The following spaces shall be provided:
(1)  Patient toilet rooms with hand-washing stations shall be immediately accessible to waiting rooms or areas and, where provided, to patient changing rooms.
(2)  Toilet rooms for imaging rooms
*(a) Where procedures performed require patient access to toilets, a patient toilet room shall be directly accessible from the imaging room.
*(b)  A patient toilet room shall be permitted to serve more than one imaging room.
(c)  Shared toilet rooms shall have interlocking door access hardware.
(3)  Toilet rooms for nuclear imaging patients
(a)  Toilet rooms reserved for nuclear imaging patients shall be immediately accessible to waiting rooms or areas and nuclear imaging rooms.
(b)  For dosed nuclear imaging patients, dedicated "hot" toilets, restricted from the use of all others for a duration from last use set by a medical physicist, shall be provided in quantities and locations to meet the needs of nuclear imaging patients.
A2.1-3.5.10.2 (2)(a) For patient comfort, some diagnostic imaging procedures necessitate direct access to a toilet room. Such procedures may include fluoroscopy, ultrasound, and CT scanning.
A2.1-3.5.10.2 (2)(b) Where a patient toilet room serves more than one imaging room, in-use (occupied) lights may be used.
  1. Where changing rooms are required, they shall be located adjacent to the imaging rooms.
  2. Each room shall include a seat or bench and mirror.
  3. Provisions for hanging patients' clothing and securing valuables shall be provided either in the patient changing room or in shared secured storage.
(1)  Waiting areas shall be screened and separated from unrelated traffic and under staff control.
(2)  Seating capacity shall be provided to accommodate the maximum expected patient volume.
(3)  Provision of waiting areas for individual modalities, or sharing of waiting areas among similar modalities, shall be permitted where patient waiting in areas adjacent to the imaging room(s) is desired.
*(4)  If so determined by an ICRA, a diagnostic imaging waiting room or area shall have special measures to reduce the risk of airborne infection transmission. These measures shall include enhanced general ventilation and air disinfection techniques similar to the requirements for airborne infection isolation rooms in Part 3 (ANSI/ASHRAE/ASHE 170: Ventilation of Health Care Facilities).
A2.1-3.5.10.4 (4) See the CDC "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings" for more information.
A2.1-3.6 Radiation therapy
  1. The services included in this section are radiation treatment modalities that use high-energy, non-radioactive beams. The exception to this is brachytherapy, which is a radiation therapy that involves placement of low-dose radioactive material in the body.
  2. Hybrid imaging/therapy systems. Where external beam radiation therapy systems are combined with a concurrent imaging option (e.g., CT or MRI), the full design criteria for both contributing imaging/therapy devices should be applied to the hybrid service.
Space shall be provided to accommodate the equipment and staff needed for planned radiation therapy services.
A2.2-3.6.2 Simulator room. Although it is not recommended, a simulator room may be omitted in small linear accelerator facilities where other positioning geometry is provided.
An examination room shall be provided for each external beam radiation therapy room. See Section 2.1-3.6.8.15 (Support Areas for Radiation Therapy-Examination room) for requirements.
*(1)  Space requirements
(a) Simulator, accelerator, brachytherapy, and cobalt rooms shall be sized to accommodate the following:
(i)  Equipment
(ii) Access to equipment for patient on a gurney
(iii) Medical staff access to the equipment and patient
(iv) Service access to equipment
(b) Radiation therapy rooms shall be sized in compliance with the manufacturer's technical specifications.
(i)   Where a table is used, the room shall be sized to provide a minimum clearance of 4 feet (1.22 meters) on three sides of the table to facilitate bed transfer and provide access to the patient.
(ii)  The door swing shall not encroach on the equipment or on patient circulation or transfer space.
A2.1-3.6.2.2 (1) Radiation therapy space requirements. The equipment manufacturer's technical specifications should be sought and followed, since space requirements may vary from one machine to another and one manufacturer to another.
  1. Support areas for the linear accelerator. Combining the mold and block rooms shall be permitted.
    1. A mold room with exhaust hood and hand-washing station shall be provided.
    2. A block room with storage shall be provided.
  2. Support area for the cobalt room. A hot lab shall be provided in accordance with Section 2.1-3.5.8.22 (Hot lab for nuclear imaging services).
A2.1-3.6.3 The radiosurgery suite houses rotating, robotic, or gantry-based external beam therapy systems of higher power and accuracy than conventional external beam therapy systems. These are called gamma knife or cyber knife systems.
  1. The radiosurgery suite shall be readily accessible to the imaging services suite to facilitate image acquisition prior to radiosurgery treatment.
  2. Examination room
    1. An examination room shall be provided for each radiosurgery room except where private pre- and post-procedure patient care stations are provided in the radiosurgery suite; in that case, the examination rooms shall not be required.
    2. See Section 2.1-3.6.8.15 (Support Areas for Radiation Therapy-Examination room) for requirements.
  1. Space requirements
    1. Area
      1. Radiosurgery (i.e., gamma knife/cyber knife) rooms shall be sized to accommodate patient access on a gurney, medical staff access to the equipment and patient, and service access.
      2. Radiosurgery rooms shall be sized and configured to accommodate the manufacturer's technical specifications.
    2. Clearances
      1. A minimum clearance of 4 feet (1.22 meters) shall be provided on all sides of the patient table for maintenance access and clearance around the table sufficient to facilitate patient transfer.
      2. The door swing shall not encroach on the equipment or on patient circulation or transfer space.
  2. Hand-washing station. A hand-washing station shall be provided in each radiosurgery room.
(1)  Where provided, pre- and post-procedure/recovery patient care stations shall meet the requirements in Section 2.1-3.7 (Pre- and Post-Procedure Patient Care).
*(2)  A gurney holding area shall not be required if each patient care station has a gurney.
A2.1-3.6.3.3 (2) The gurney hold area is not required in this case because the gurney moves with the patient.
The following support spaces and/or areas shall be provided:
  1. Space for sterilization of head-frames
  2. Target planning
  3. Medication safety zone. See Section 2.1-3.8.8 (Medication Safety Zones) for requirements.
  4. Nourishment/mini-fridge
  5. Storage for head-frames. Location of this at each pre- and post-procedure patient care station shall be permitted.
  6. Separate toilet room(s) for patients and staff
  7. Area for sedation of pediatric patients
  1. Frame pin sterilization. A work counter to accommodate a small autoclave shall be provided.
  2. Source delivery route. Where a radiosurgery device that uses a radioactive source is installed, a delivery route that meets the manufacturer's requirements shall be provided.
  1. Where individual pre-procedure/recovery positions in cubicles or rooms are provided, separate patient changing areas shall not be required.
  2. Storage for patient belongings shall be provided.
  1. Application. Rooms and spaces shall be provided to accommodate the equipment manufacturer's technical specifications.
  2. Location. Location of proton therapy facilities in a radiation therapy suite shall be permitted.
  3. Examination room. Two examination rooms shall be provided for each proton therapy room. See Section 2.1-3.6.8.15 (Support Areas for Radiation Therapy-Examination room) for requirements.
A2.1-3.6.4.1 The proton therapy suite will contain neutron beam therapy and possibly diagnostic x-ray radiation. Proton therapy technology is provided under a wide range of beam dose preparation technologies and dose applications.
*(1)  Space requirements. Proton therapy rooms shall be sized to:
(a) Accommodate the following:
(i)   Proton therapy equipment
(ii)  Patient access on a gurney
(iii) Medical staff access to the equipment
(iv) Patient in-room storage of equipment devices
(v)  Service access
(b) Accommodate a balance between clinical support requirements and the needs of the specific equipment.
(i)   The room shall be sized to provide a minimum clearance of 4 feet (1.22 meters) on three sides of the patient table to facilitate bed transfer and provide access to the patient.
(ii)  The door swing shall not encroach on the equipment or on patient circulation or transfer space.
(2)  Cyclotron vault. Cyclotron facility program requirements depend on specific proton therapy equipment and facility equipment type.
(3)  A hand sanitation dispenser shall be located immediately inside or outside the entrance to the proton therapy room.
A2.1-3.6.4.2 Proton therapy equipment requirements. The space, clearance, access, building system support, and shielding requirements for proton therapy equipment vary greatly from vendor to vendor. Therefore, before undertaking planning and design, the type of proton therapy device to be used should be determined.
A2.1-3.6.4.2 (1) Minimum room size volume and configuration can vary significantly depending on the equipment used.
Two gurney hold bays shall be provided for each proton therapy room.
  1. These shall be located adjacent to the proton therapy rooms and screened for privacy.
  2. A separate waiting area shall be provided for queued patients.
The following shall be provided:
(1)  General supply storage in proton therapy room for patient care supplies
(2)  Storage for patient positioning devices. Location of this storage shall be permitted in or next to the proton therapy room.
*(3)  Storage for patient-specific therapy devices (e.g., apertures and compensators)
*(4)  Post-treatment storage for patient-specific therapy devices (e.g., apertures and range compensators)
(a) This shall be a separate shielded room. Requirements for radioactive shielding shall be verified by a certified radiophysicist.
(b) This storage room does not need to be in the immediate vicinity of the proton therapy suite.
(c) Sharing of this room with other services shall be permitted.
A2.1-3.6.4.6 (3) These devices are normally stored in the proton therapy room. They can be heavy and sometimes require a cart or wheeled trolley to move and position.
A2.1-3.6.4.6 (4) The need for this storage should be anticipated to allow for the radioactivity level to fall below NRC regulatory limits.
(1)  The floor structure shall meet the minimum load requirements for equipment, patients, and personnel.
(2)  Ceiling-mounted equipment shall have properly designed rigid support structures located above the finished ceiling.
*(3)  Where entry into the radiation vault is via direct-shielded door, both a motor-driven automatic opening system and a manual emergency opening system shall be provided.
(4)  The height and width of doorways, elevators, and mazes shall allow delivery of equipment and replacement sources into radiation therapy rooms.
*(5)  Radiation protection requirements
(a) Radiation protection shall be provided in cobalt, linear accelerator, and simulation rooms; radiosurgery rooms; and proton therapy rooms.
(b) Both photons and neutrons shall be taken into account in the shielding for electron accelerators of higher energy.
(c) Layouts shall be designed to prevent the escape of radioactive particles.
*(d) Openings into the room, including doors, ductwork, vents, and electrical raceways and conduits, shall be baffled to prevent direct exposure to other areas of the facility.
(e) Physicist and vendor input shall be obtained in the design process.
(i)   A certified physicist representing the owner or appropriate state agency shall specify the type, location, and amount of protection to be installed in accordance with final approved department layout and equipment selection.
(ii)  The architect shall incorporate these specifications into the building plans.
A2.1-3.6.7.1 (3) Use of a maze can greatly decrease the shielding requirement for the shielded door. For higher energy rooms, an extra door constructed of thermal neutron absorbing material at the inside of the maze may reduce the required length for the maze or the shielding requirement for the outside door.
A2.1-3.6.7.1 (5) Detailed discussion and design criteria can be obtained through the documents listed. Also see Section 2.1-7.2.2.11 (Radiation protection).
  1. National Council on Radiation Protection and Measurements (NCRP) Report 116: Limitation of Exposure to Ionizing Radiation
  2. NCRP Report 144: Radiation Protection for Particle Accelerator Facilities
  3. NCRP Report 151: Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities
  4. Nuclear Regulatory Commission Title 10 CFR Part 20: Standards for Protection Against Radiation
  5. Sullivan, A. H. A Guide to Radiation and Radioactivity Levels Near High Energy Particle Accelerators (Nuclear Technology Publishing, 1992).
  6. Tesch, K. "A Simple Estimation of the Lateral Shielding for Proton Accelerators in the Energy Range of 50 to 1000 MeV," Radiation Protection Dosimetry 11:165-72 (1985).
  7. Tesch, K. "The Attenuation of the Neutron Dose Equivalent in a Labyrinth Through an Accelerator Shield," Particle Accelerators 12:169-75 (1982).
A2.1-3.6.7.1 (5)(d) Ducts should be oriented to minimize direct radiation passing through the aperture and to allow the least possible amount of concrete displacement in the direction of the radiation beam. For rooms that have mazes, the ideal location for duct penetrations is directly through the shielding above the door since that location has the lowest neutron and photon flux. For rooms without mazes, the walls parallel to the gantry (which have lower shielding requirements than those in the gantry rotation plane) should be used for duct penetrations. Detailed discussion of this topic can be found in NCRP Report 151: Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities.
The support areas in this section shall be provided. Sharing of these areas between different services in the radiation therapy suite or other areas shall be permitted.
  1. A gurney storage area shall be immediately accessible to the radiation therapy rooms.
  2. The gurney storage area shall be permitted to be combined with a waiting area.
This shall be provided in accordance with Section 2.1-5.3.1 (Environmental Services Room).
  1. Each examination room shall have a minimum clear floor area of 100 square feet (9.29 square meters).
  2. Each examination room shall be equipped with a hand-washing station.
Optional support areas for radiation therapy. Where the support areas listed are provided, they shall meet the requirements in this section.
  1. Offices
    1. Oncologist's office. Combination of this office with a consultation room shall be permitted.
    2. Physicist's office. Combination of this office with the treatment planning and record room shall be permitted.
  2. Consultation room. Private prep/holding rooms shall be permitted to be used in lieu of a dedicated consultation room.
  3. Quality control area. This area shall have an image viewing station.
A2.1-3.6.8.16 Other support areas for radiation therapy. In addition to the optional support areas in the main text, the following support areas may be needed to support radiation therapy services:
  1. Treatment planning and record room
  2. Computer control area. This is usually located just outside the entry to the radiation therapy room(s).
  3. Dosimetry equipment area or storage for calibration phantoms
  4. Workstation/nutrition station
Toilet rooms reserved for radiation therapy patients shall be directly accessible to waiting areas and procedure rooms.
Two gowning cubicles shall be provided for each proton therapy room.
  1. Secure storage for valuables and clothing shall be provided.
  2. At least one space shall be large enough for staff-assisted dressing.
  1. A waiting area for gowned patients shall be provided adjacent to the changing area.
  2. Provisions shall be made for patient privacy in the waiting area.
Patient care stations shall be provided to accommodate lounge chairs, gurneys, or beds for pre- and post-procedure (recovery) patient care as well as seating space for family/visitors.
The pre- and post-procedure patient care area(s) shall be an unrestricted areas.
  1. Layout. The following arrangements shall be permitted as long as all patient care stations combined in the same area meet the most restrictive requirements of the areas to be combined.
    1. Combination of pre- and post-procedure patient care stations in one patient care area
    2. Separate pre-procedure patient care area and post-procedure recovery area
    3. Three areas: pre-procedure patient care area, Phase I post-anesthesia care unit (PACU), and Phase II recovery area
  1. Where pre- and post-procedure patient care stations are combined in one patient care area, at least one patient care station shall be provided for each imaging, procedure, or operating room.
  2. Where separate pre-procedure and recovery areas are provided, the number of patient care stations shall be as required in these sections:
    1. Section 2.1-3.7.3 (Pre-Procedure Patient Care Room or Area)
    2. Section 2.1-3.7.4 (Phase I Post-Anesthesia Recovery Room)
    3. Section 2.1-3.7.5 (Phase II Recovery Room or Area)
A2.1-3.7.1.4 Determining the number of patient care stations. When designing the pre- and post-procedure patient care area(s) and determining the number of patient care stations required, consideration should be given to the types of surgery and procedures performed, volume of patients to be served, and anticipated staffing levels.
Bays, cubicles, or single-patient rooms that meet the requirements in this section shall be permitted to serve as patient care stations.
(1)  Area. When determining the area for a patient care station, space shall be provided to accommodate the equipment to be used.
*(2)  Clearances
(a) Where bays are used, the following minimum clearances shall be provided:
(i)   5 feet (1.52 meters) between the sides of patient beds/gurneys/lounge chairs
(ii)  3 feet (91.44 centimeters) between the sides of beds/gurneys/lounge chairs and adjacent walls or partitions
(iii) 2 feet (60.96 centimeters) between the foot of beds/gurneys/lounge chairs and the cubicle curtain
(b) Where cubicles are used, the following minimum clearances shall be provided:
(i)   3 feet (91.44 centimeters) between the sides and foot of beds/gurneys/lounge chairs and adjacent walls or partitions.
(ii)  2 feet (60.96 centimeters) between the foot of beds/gurneys/lounge chairs and the cubicle curtain
(c) Where bays or cubicles face each other, an aisle with a minimum clearance of 8 feet (2.44 meters) independent of the foot clearance between patient stations or other fixed objects shall be provided.
(d) Where single-patient rooms are used, 3 feet (91.44 centimeters) shall be provided between the sides and foot of beds/gurneys/lounge chairs and adjacent walls or partitions.
A2.1-3.7.2.2 (2) Two bays may be used to accommodate non-standard equipment (e.g., an expanded-capacity patient bed), but clearances do not include any area that would have to be shared to meet the standard. Clearances noted around gurneys are between the normal use position of the gurney and any adjacent fixed surface or between adjacent gurneys.
Provisions shall be made for patient privacy in accordance with Section 2.1-3.1.2 (Patient Privacy).
See Section 2.1-3.8.7 (Hand-Washing Station) for requirements.
  1. For electrical receptacle requirements, see Table 2.1-1 (Electrical Receptacles for Patient Care Areas in Outpatient Facilities).
  2. For nurse call requirements, see Table 2.1-3 (Locations for Nurse Call Devices in Outpatient Facilities).
  3. For oxygen and vacuum requirements, see Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities).
Where a separate pre-procedure patient care room or area is provided, a minimum of one patient care station per imaging, procedure, or operating room shall be provided.
A minimum of one Phase I patient care station per Class 3 imaging or operating room shall be provided.
At least one door to the recovery room shall provide access directly from the semi-restricted area without crossing a public corridor.
The design of the Phase I recovery area shall provide observation of all patient care stations from the nurse station(s).
A minimum of one Phase II patient care station per Class 2 and Class 3 imaging, procedure, or operating room shall be provided.
A nurse station shall include the following:
Work counter
Means for facilitating staff communication
A2.1-3.8.2.2 Means for facilitating staff communication. This can be a nurse call system, telephone, or similar device.
Space for supplies
Accommodations for written or electronic documentation
Hand sanitation dispenser
Accommodations for written and/or electronic documentation shall be provided as indicated in other sections of this chapter and in the facility type chapters.
A2.1-3.8.3 Documentation area. Accommodations for documentation should include a writing surface and/or area with storage for an electronic device.
At least one hand scrub position shall be located in the semi-restricted area adjacent to the entrance to each operating room and Class 3 imaging room.
One hand scrub station consisting of two scrub positions shall be permitted to serve two Class 3 imaging or operating rooms if located adjacent to the entrance of each room.
The placement of the scrub station(s) shall not restrict the minimum required corridor width.
A2.1-3.8.6.3 Scrub station(s) may be recessed into an alcove to reduce the likelihood of incidental splatter on adjacent personnel or equipment. The alcove depth and/or configuration should enable personnel in the scrub process to keep their hands and arms below the elbow over the sink compartment without interference from other staff and equipment/stretchers passing in adjacent circulation areas. Scrub sink dimensions (particularly depth), which vary between manufacturers, should be considered when determining the space needed to accommodate the sink and clearance necessary beyond the front lip for personnel in the scrub process to be clear of adjacent activity.
Hand-washing stations shall be provided in each room where hands-on patient care is provided. For location and number requirements, see other common elements sections and the facility chapters.
Hand-washing stations shall meet the requirements in the following sections:
  1. For hand-washing station design details, see Section 2.1-7.2.2.8 (Architectural Details-Hand-washing stations).
  2. For hand-washing station sink requirements, see Section 2.1-8.4.3.2 (Plumbing Fixtures-Hand-washing station sinks).
Additional requirements for hand-washing stations that serve multiple patient care stations
(1)  At least one hand-washing station shall be provided for every four patient care stations or fewer and for each major fraction thereof.
*(2)  Based on the arrangement of the patient care stations, hand-washing stations shall be evenly distributed.
A2.1-3.8.7.3 (2) Distribution of hand-washing stations. In a linear arrangement of patient care stations, the distance from the two stations farthest from the hand-washing station should be approximately equal. In a circular arrangement, the distance from all patient care stations should be approximately equal.
(1)  Application. Where medication is prepared or dispensed, medication safety zones shall be provided as defined in this section for preparing, dispensing, storing, and administering medications.
(a) The number and location of medication safety zones shall be as determined in the medication safety risk assessment. See Section 1.2-4.5 (Medication Safety Assessment).
(b) A medication preparation room or area, self-contained medication dispensing unit, automated medication-dispensing station, or other system approved by the authority having jurisdiction (AHJ) shall be permitted to serve as a medication safety zone.
*(2)  Design requirements. Medication safety zones shall meet the following physical environment requirements that promote safe medication use:
*(a) Medication safety zones shall be located out of circulation paths.
*(b)  Work space for medication safety zones shall be designed so that staff can access information and perform required tasks. See Section 1.2-4.5 (Medication Safety Assessment).
(c) Work counters shall provide space to perform the tasks described in paragraph (b).
*(d) Lighting. Task-specific lighting levels for health care settings recommended in the U.S. Pharmacopeia-National Formulary shall be used to design lighting.
*(e) Where sharps containers are provided, they shall be placed at a height that allows users to see the top of the container.
A2.1-3.8.8.1 (2) Medication safety zone design requirements. The physical environment requirements listed in Section 2.1-3.8.8.1 (2) are found in General Chapter <1066> "Physical Environments that Promote Safe Medication Use" of the U.S. Pharmacopeia-National Formulary (USP-NF).
A2.1-3.8.8.1 (2)(a) Locating medication safety zones out of circulation paths minimizes the potential for distractions and interruptions that interfere with staff concentration and attentiveness to medication therapy activities.
  1. Work space elements should be described in the functional program to assure medication safety zones can support effective use of medication-related information and accurate performance of tasks. Elements to consider include:
    • -Number of staff working in the medication safety zone
    • -Key tasks being performed
    • -Amount of space needed to support tasks being performed
    • -Types of products that should be clearly visible, enabled by the use of adjustable fixtures, drawer and storage design, and counter height
    • -Designs to minimize work surface clutter
  2. Space, power, and data requirements for medication-associated equipment and safety technology should be detailed in the functional program so the facility design will be able to accommodate the equipment and technology to be used in the medication safety zone.
A2.1-3.8.8.1 (2)(d) Lighting for medication safety zone work areas. Detailed lighting recommendations for medication safety zone work areas can be found in USP-NF General Chapter <1066> "Physical Environments that Promote Safe Medication Use."
A2.1-3.8.8.1 (2)(e) Height of sharps containers. NIOSH provides an ergonomically ideal formula for determining the height of sharps containers by establishing the eye-level height and maximum thumb tip reach of the worker population and then adding a drop angle of 15 degrees. For a standing work station, the sharps container height should be 52 to 56 inches above the standing surface of the user. For a seated work station, the sharps container height should be 38 to 42 inches above the floor on which the chair rests. These height recommendations will comfortably accommodate 95 percent of adult female workers. See HHS (NIOSH) Publication No. 97-111, "Selecting, Evaluating, and Using Sharps Disposal Containers."
  1. Medication preparation room
    1. The medication preparation room shall contain the following:
      1. Work counter
      2. Hand-washing station
      3. Lockable refrigerator
      4. Locked storage for controlled drugs
      5. Sharps containers, where sharps are used
    2. Where a medication preparation room is used to store one or more self-contained medication dispensing units, the room shall be designed with space to prepare medication when the self-contained medication-dispensing unit(s) is present.
    3. Where a medication preparation room is used to compound sterile preparations, it shall meet the requirements in USP-NF General Chapter <797> "Pharmaceutical Compounding-Sterile Preparations."
  2. Self-contained medication-dispensing units, automated medication-dispensing stations, or other systems approved by the AHJ
    1. Use of units or stations shall be permitted in the following locations provided the unit or station can be locked to secure controlled drugs:
      1. At a nurse station
      2. In a clean workroom
      3. In an alcove
    2. A hand-washing station or hand sanitation dispenser shall be provided next to stationary medication-dispensing units or stations.
    3. A countertop or cart shall be provided adjacent to stationary medication-dispensing units or stations.
A2.1-3.8.8.2 Security controls. Medication work areas may require physical environment components such as electronic surveillance, password-controlled access, and view panels in doors for security.
Where nourishment areas or rooms are provided, they shall have the following:
Hand-washing station in or directly accessible to the nourishment room or area
Work counter
Storage
Fixtures and appliances for the beverages and/or nourishment provided in the facility
In public areas, ice-making equipment shall be of the self-dispensing type.
In areas restricted to staff only, use of storage bin-type equipment for making and dispensing ice shall be permitted.
Clean workrooms and clean supply rooms shall be separate from and have no direct connection with soiled workrooms or soiled holding rooms.
Where a clean workroom is provided, it shall contain the following:
  1. Work counter
  2. Hand-washing station
  3. Storage facilities for clean and sterile supplies
A room used only for storage and holding as part of a system for distribution of clean and sterile materials does not require a work counter or a hand-washing station.
A2.1-3.8.12 Functions for soiled workroom and soiled holding room
  1. Soiled workroom. Soiled items may be handled in a soiled workroom to prepare them for subsequent cleaning, disposal, or reuse (e.g., emptying and rinsing bedpans or emesis basins, emptying or solidifying suction canisters, rinsing and gross cleaning of medical instruments). As well, this room provides temporary storage for soiled items prior to their removal from the unit.
  2. Soiled holding room. This location is used for temporary storage of soiled materials and/or supplies prior to their removal from the facility.
Soiled workrooms or soiled holding rooms shall not have a direct connection with clean workrooms or clean supply rooms.
  1. Where a soiled workroom is provided, it shall contain the following:
    1. Hand-washing station
    2. Flushing-rim clinical service sink or equivalent flushing-rim fixture
    3. Work counter
    4. Space for separate covered containers for waste and soiled linen
  2. Where a fluid management system is used, the following shall be provided in the soiled workroom:
    1. Electrical and plumbing connections that meet manufacturer requirements
    2. Space for the docking station(s)
Where a soiled holding room is provided, it shall contain the following:
  1. Hand-washing station or hand sanitation dispenser
  2. Space for separate covered containers for waste and soiled linen
See Section 2.1-6.2.7 (Wheelchair Storage and Parking Space) for requirements.
  1. Storage shall be provided for the emergency equipment used in the facility.
  2. Each storage location shall be readily accessible and under staff control.
  3. Where a battery-powered CPR cart is stored, an electrical outlet for battery charging shall be provided.
A2.1-3.8.13.4 Emergency equipment such as a cardiopulmonary resuscitation (CPR) cart(s) is often positioned in an alcove when located in a corridor.
Staff changing area(s) shall contain the following:
  1. Lockers
  2. Toilets
  3. Hand-washing stations
  4. Space for donning surgical attire
  5. Provision for separate storage for clean and soiled surgical attire
Staff changing area(s) are unrestricted areas.
Patient toilet room(s) shall be provided separate from public use toilet room(s) and located to permit access from patient care areas without passing through publicly accessible areas.
Patient toilet rooms shall be equipped with a toilet(s) and a hand-washing station(s).
Table 2.1-4
Examination/Treatment, Procedure, and Operating Room Classification1
Room Use Design Requirements2
Room Type Location Surfaces
Exam or treatment room Patient care that may require high-level disinfected or sterile instruments but does not require the environmental controls of a procedure room Unrestricted area Accessed from an unrestricted area Flooring: cleanable and wear-resistant for the location; stable, firm, and slip-resistant

Wall finishes: washable

Ceiling: cleanable with routine housekeeping equipment; lay-in ceiling permitted
Procedure room Patient care that requires high-level disinfected or sterile instruments and some environmental controls but does not require the environmental controls of an operating room

Endoscopic procedures
Semi-restricted area Accessed from an unrestricted or a semi-restricted area Flooring: cleanable and wear-resistant for the location; stable, firm, and slip-resistant

Floor and wall base assemblies in cystoscopy, urology, and endoscopy procedure rooms: monolithic floor with integral coved wall base carried up the wall a minimum of 6 inches

Wall finishes: washable; free of fissures, open joints, or crevices

Ceiling: smooth and without crevices, scrubbable, non-absorptive, non-perforated; capable of withstanding cleaning chemicals; lay-in ceiling permitted if gasketed or each ceiling tile weighs at least one pound per square foot and no perforated, tegular, serrated, or highly textured tiles
Operating room Invasive procedures3

Any procedure during which the patient will require physiological monitoring and is anticipated to require active life support
Restricted area Accessed from a semi-restricted area Flooring: cleanable and wear-resistant for the location; stable, firm, and slip-resistant

Floor and wall base assemblies: monolithic floor with integral coved wall base carried up the wall a minimum of 6 inches

Wall finishes: washable; free of fissures, open joints, or crevices

Ceiling: monolithic, scrubbable, capable of withstanding cleaning and/or disinfecting chemicals, gasketed access openings
1This table includes a brief description of what clinical services are performed in these room types and a summary of some applicable requirements that appear elsewhere in the 2018 Guidelines for Design and Construction of Outpatient Facilities. The table has been provided to help users determine when an examination/treatment, procedure, or operating room is required for a project. "Examination room," "treatment room," "procedure room," and "operating room" are defined in the glossary.
2Other design requirements that apply to these room types include, but are not limited to, ventilation, lighting, and sound transmission requirements. See Part 3 (ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities) for ventilation requirements for these rooms. See Section 2.1-8.3.4.3 (Lighting for specific locations in outpatient facilities) and facility chapters for lighting requirements and Section 1.2-6.1 (Acoustic Design) for noise transmission requirements.
3"Invasive procedure" is defined in the glossary.
Facilities for laboratory services provided on-site shall be located in or immediately accessible to the outpatient facility and shall meet the requirements in this section.
A2.1-4.1.1.1 Certain tests may be performed on-site or provided through a contractual arrangement with a laboratory service. When testing is performed on-site, space and facilities will be needed to accommodate these services. Testing may include hematology, clinical chemistry, urinalysis, coagulation, genetic testing, molecular diagnostics, toxicology, microbiology, anatomic pathology (including cytology and histology), and blood banking as well as tests for blood glucose, arterial blood gases, and electrolytes.
All laboratory equipment requiring permanent connections to power, water, ventilation, or other utility systems shall be identified in the equipment plan included in the contract documents.
Where lab tests are performed on-site, a separate, dedicated room shall be provided. However, tests that are waived by the Food and Drug Administration (FDA) under the Clinical Laboratory Improvement Amendments (CLIA) shall be permitted to be performed in areas open to other spaces.
A2.1-4.1.2.1 Lists of currently waived CLIA tests can be accessed from the Centers for Medicare & Medicaid (CMS) website: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Categorization_of_Tests.html.
  1. Workstations shall be sized to accommodate the equipment used and, at minimum, shall include the following:
    1. Work counter
    2. Sink(s)
  2. Access to the following shall be provided as required:
    1. Vacuum and gases
    2. Tele/data service
    3. Computer/printer
  1. At least one hand-washing station shall be provided.
  2. Additional hand-washing stations shall be provided based on the safety risk assessment.
All work counter(s) in areas used for specimen handling, preparation of specimens or reagents, and laboratory testing shall be constructed of non-porous materials.
A2.1-4.1.2.4 Reagent water systems. Deionized or reverse osmosis reagent water systems should be designed in accordance with ASTM D1193: Standard Specification for Reagent Water.
  1. Terminal sterilization provisions. Facilities and equipment (autoclave or electric oven) shall be provided for terminal sterilization of bio-hazardous waste before transport.
    1. Terminal sterilization is not required for waste that is incinerated on-site.
    2. If the facility includes a biosafety Level III lab, autoclave requirements shall conform to Section IV of the CDC Biosafety in Microbiological and Biomedical Laboratories (BMBL).
  2. Radioactive material-handling provisions. If radioactive materials are employed, facilities for long-term storage and disposal of these materials shall be provided in accordance with the requirements of authorities having jurisdiction.
A2.1-4.1.2.5 Safety and security provisions
  1. Additional security information can be found in Section 02.09 Biological, Chemical and Radiation Areas, in the Security Design Guidelines for Healthcare Facilities, published by the International Association for Healthcare Security & Safety (IAHSS).
  2. Eyewash and emergency showers. The number and location of eyewash and emergency showers needed is based on requirements from different occupational safety organizations at local, state, and federal levels. The application of these requirements depends on the types and volumes of chemicals used in a lab. Health care organizations should consult with the local authority having jurisdiction to determine these requirements.
*(1)  Storage shall be provided for reagents, specimens, flammable materials, acids, bases, and other supplies used in the laboratory.
A2.1-4.1.8.1 (1) Depending on the quantities of these materials stored, storage may need to comply with the requirements of NFPA 400: Hazardous Materials Code and/or NFPA 30: Flammable and Combustible Liquids Code, where applicable.
  1. In facilities where urine or feces specimens are collected, a toilet room with hand-washing station and staff-controlled access shall be provided.
  2. In facilities where collection for drug screening that requires chain-of-custody urine samples is performed, the hand-washing station shall either be directly outside the toilet room and under staff control or in the toilet room if the water is controlled by shutoff valves located outside the room and directly accessible to staff.
  3. Blood collection facilities shall have:
    1. Work counter
    2. Seating space for patients
    3. Hand-washing station
    4. Supply storage
Space(s) for clerical work, filing, and record maintenance and storage shall be provided.
Lounge, locker, and toilet facilities shall be readily accessible for laboratory staff.
Location of these areas outside the laboratory area and sharing of these areas with other clinical services shall be permitted.
  1. Where pharmacy services are provided in the outpatient facility, facilities shall be provided to accommodate the pharmacy services and associated equipment.
  2. Pharmacy facilities shall be designed to address risks identified in the medication safety assessment and security risk assessment portions of the safety risk assessment.
  3. Satellite pharmacy facilities shall be permitted.
A2.1-4.2.1.1 Pharmacy services. The size and type of services to be accommodated in the pharmacy depend on the type of drug distribution system used, the number of patients to be served, and the extent of shared or purchased services.
*(1)  Where clinical services being provided require on-site pharmacy services, a pharmacy room or suite shall be located in the same building.
*(2)  Access to the room or suite shall be controlled.
A2.1-4.2.1.2 (1) For a clinical service that requires a dedicated pharmacy, the pharmacy room or suite should be immediately accessible to the clinical service area where feasible.
A2.1-4.2.1.2 (2) Controlled access to the pharmacy. Additional security information can be found in Security Design Guidelines for Healthcare Facilities, published by the International Association for Healthcare Security & Safety (IAHSS). Architectural hardening to avoid break-ins is recommended.
See Section 2.1-3.8.8 (Medication Safety Zones) for general requirements for design of medication safety zones.
The following shall be provided where dispensing takes place:
  1. A room or area for receiving, unpacking, and inventory control of materials used in the pharmacy
  2. Work counters and space for automated and/or manual dispensing activities
  3. An extemporaneous compounding area, where compounding takes place. This shall include a sink and counter space for drug preparation.
  4. An area for reviewing and recording
  5. An area for temporary storage, exchange, and restocking of carts, where a cart system is used
  6. Security provisions for drugs and personnel in the dispensing counter area
A2.1-4.2.2.1 Dispensing facilities. Dispensing facilities should meet all applicable requirements of:
  1. USP <795>: Pharmaceutical Compounding-Nonsterile Preparations
  2. USP <797>: Pharmaceutical Compounding-Sterile Preparations
  3. USP <800>: Hazardous Drugs-Handling in Healthcare Settings
The following shall be provided where drugs are compounded on-site:
  1. A bulk compounding area
  2. Provisions for packaging and labeling
  3. A quality control area
Cabinets, shelves, and/or separate rooms or closets shall be provided for the following:
(1)  Bulk storage
(2)  Active storage
(3)  Refrigerated storage
(4)  Storage for volatile fluids and alcohol in accordance with applicable fire safety codes for the substances involved
*(5)  Secured lockable storage for narcotics and controlled drugs
(6)  Equipment and supply storage for general supplies and equipment not in use
A2.1-4.2.2.3 (5) Storage should be in accordance with the Code of Federal Regulations, Title 21.
Where sterile work areas are provided, they shall meet the requirements in this section.
  1. Layout. The pharmacy shall be laid out to preclude unrelated traffic through the intravenous (IV) and hazardous drug IV preparation rooms.
  2. Where robotic systems are used in the preparation of IV solutions in either the positive pressure IV preparation room or the negative pressure hazardous drug IV prep room, the robotics shall be separate systems and shall not pass from one room to the other.
A2.1-4.2.3.1 General. Sterile work areas should meet the requirements of USP <797>: Pharmaceutical Compounding-Sterile Preparations and USP <800>: Hazardous Drugs-Handling in Healthcare Settings as applicable.
Where IV solutions are prepared in the pharmacy, a sterile work area with a laminar-flow workstation designed for product protection shall be provided.
  1. The laminar-flow workstation shall include a nonhydroscopic filter rated at 99.97 percent (HEPA), as tested by dioctyl phthalate (DOP) tests.
  2. The laminar-flow workstation shall have a visible pressure gauge for detection of filter leaks or defects.
A separate room shall be provided for preparation of hazardous drug IV admixtures under a Class II (Type A2, B1, or B2) or Class III biological safety cabinet.
A2.1-4.2.3.3 Biological safety cabinets are classified according to biosafety levels established by the Centers for Disease Control and Prevention. See the CDC publication "Primary Containment for Biohazards: Selection, Installation and Use of Biological Safety Cabinets." The hazardous drug IV preparation room should meet the requirements of USP <800>: Hazardous Drugs-Handling in Healthcare Settings.
  1. Patient information. Provision shall be made for cross-checking medication and drug profiles of individual patients.
  2. Pharmacological information. Provision shall be made for access to poison control, reaction data, and drug information.
A2.1-4.2.8.3 Access to information. Where access to patient and pharmacological information is via a computer, consideration should be given to provision of backup access during a power failure or a failure of the health care organization's electronic data system.
A separate room or area shall be provided for office functions.
A2.1-4.2.8.4 Office. When sizing this room, consider the space needed to accommodate a desk, filing capabilities, communication equipment, and reference materials.
A hand-washing station(s) shall be provided either in an anteroom or immediately outside the room where open medication(s) are prepared.
A2.1-4.2.8.7 The hand-washing station(s) should be in accordance with the following, as applicable:
  1. USP <795>: Pharmaceutical Compounding-Nonsterile Preparations
  2. USP <797>: Pharmaceutical Compounding-Sterile Preparations
  3. USP <800>: Hazardous Drugs: Handling in Healthcare Settings
If medication is dispensed directly to patients from the pharmacy, an area for consultation and patient education shall be provided.
If a unit dose procedure is used, additional space and equipment shall be provided to accommodate supplies, packaging, labeling, and storage, including space for carts.
Lounge, locker, and toilet facilities shall be readily accessible to the pharmacy staff.
These areas shall be permitted to be outside the pharmacy area and shared with other departments.
Sterile processing facilities required in the facility chapters in Part 2 shall meet requirements in this section.
(1)  Application
(a) Where sterile processing is provided on-site, sterile processing facilities that comply with Section 2.1-4.3.2.2 (Two-room sterile processing facility) shall be provided with the following exception:
(b) Where sterilization equipment is limited to a table-top or similar-sized sterilizer(s), provision of a one-room sterile processing facility that complies with Section 2.1-4.3.2.3 (One-room sterile processing facility) shall be permitted.
(2)  The sterile processing facility shall meet the requirements of a semi-restricted area.
*(3)  Layout. Sterile processing facilities shall be designed to provide a one-way traffic pattern.
A2.1-4.3.2.1 (3) One-way traffic in sterile processing. The process for cleaning contaminated instruments and reprocessing items for patient use is: The contaminated item is transported from the point of use to the decontamination room or decontamination area, where it is cleaned. The clean item is then moved to the clean workroom or clean work area, where it is readied for sterilization, packaged, and sterilized.
(1)  General
*(a) The two-room sterile processing facility shall consist of a decontamination room and a clean workroom that are physically separated by a wall containing a door or pass-through window that can be closed and secured or a built-in washer/disinfector with a pass-through door or window.
(b) A sterilizer access room for maintaining the equipment shall be provided if required by the sterilizer manufacturer.
(2)  Decontamination room
*(a) The decontamination room shall be sized to accommodate the minimum space and clearances needed for the equipment used.
(b) In addition to space for equipment, the decontamination room shall contain the following:
(i)   Work counter(s)
(ii)  Hand-washing station
(iii) Three-basin sink with counter
(iv) Flushing-rim clinical sink or equivalent fixture unless alternative methods for disposal of bio-waste are provided
(v)  Space for waste and soiled linen receptacles(s)
(vi) Documentation area
(vii) Instrument air outlet or portable compressed air for drying instruments. See Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities).
(viii) Eyewash station if required by the safety risk assessment
(ix) Storage for decontamination supplies and personal protective equipment (PPE)
(3)  Clean workroom
*(a) The clean workroom shall be sized to accommodate the space and clearances needed for the sterilization equipment used.
(b) In addition to space for equipment, the clean workroom shall contain the following:
*(i)  Work counter(s)
(ii) Hand-washing station
(iii) Eyewash station if required by the safety risk assessment
(iv) Storage for sterilization supplies
(v)  Documentation area
(vi) Instrument air outlet or portable compressed air as required by equipment used to dry instruments. See Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities).
(vii) Cooling area for sterilization cart where the sterilizer is loaded/unloaded using a rolling cart
(4)  Sterile storage. A sterile storage space shall be provided for storage of sterile instruments and supplies.
(a) This space shall be permitted to be in the clean workroom or a separate storage room.
(b) Space for case cart storage shall be provided where case carts are used.
A2.1-4.3.2.2 (1)(a) The intent of this requirement is to support a work flow in which decontaminated items are transferred directly to the clean workroom for final assembly, packaging, and sterilization. This direct flow pattern reduces the risk of environmental contamination of adjoining corridors and other spaces.
A2.1-4.3.2.2 (2)(a) Decontamination room equipment. Equipment used in the decontamination room may include:
  1. Washer/sterilizer or washer/decontaminator
  2. Ultrasonic cleaner
  3. Case cart washer, where carts are used
  4. Case cart storage, where carts are used
A2.1-4.3.2.2 (3)(a) Clean workroom equipment. Equipment used in the clean workroom may include:
  1. Steam sterilizer (manual load, cart, or countertop)
  2. Low-temperature sterilizer (may be countertop)
A2.1-4.3.2.2 (3)(b)(i) The work counter space provided should be able to accommodate the volume of equipment assembly for the procedures performed in the facility and the expected staffing levels.
(1)  General. The one-room sterile processing facility shall consist of a decontamination area and a clean work area.
(a) Location of the clean work area in an alcove or in a clean workroom as described in Section 2.1-3.8.11 (Clean Workroom or Clean Supply Room) shall be permitted provided decontamination takes place in a readily accessible soiled workroom as described in Section 2.1-3.8.12 (Soiled Workroom or Soiled Holding Room).
*(b)  One-room sterile processing facilities shall be permitted to have one entrance provided it is located approximately equidistant from the clean and decontamination sides of the room and allows for a one-way traffic flow.
(2)  Decontamination area
(a) The decontamination area shall be equipped with the following:
(i)  Countertop
(ii) Hand-washing station separate from the instrument-washing sink
(iii) Two-basin sink for washing instruments
(iv) Storage for supplies
(v)  Instrument air outlet or portable compressed air as required by equipment used to dry instruments. See Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities).
(b) To avoid splash, the instrument-washing sink shall be separated from the clean work area by either a 4-foot (1.22-meter) distance from the edge of the sink or a separating wall or screen. If a screen is used, it shall extend a minimum of 4 feet (1.22 meters) above the sink rim.
(3)  Clean work area. The clean work area shall be equipped with the following:
(a) Countertop
(b) Sterilizer as required for the services provided
(c) Storage for supplies
(d) Instrument air outlet or portable compressed air as required by equipment used to dry instruments. See Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities).
A2.1-4.3.2.3 (1)(b) A one-way traffic flow may also be created by placing a door at or near the ends of both the clean and decontamination areas.
(1)  Instrument and supply storage. Storage shall be provided for sterile and clean instruments and supplies.
(a) This storage shall be permitted to be a separate room or a portion of the clean workroom.
(b) Space for case cart storage shall be provided where case carts are used.
(c) Storage for clean/sterile packs shall include provisions to maintain humidity and temperature levels specified by the manufacturer(s) of the materials being stored.
*(2)  Clean/sterile medical/surgical supply receiving room or area. A room or area shall be provided for receiving/unpacking clean/sterile supplies received from outside the department or facility.
A2.1-4.3.2.4 (2) A receiving room or area is required because the exterior containers in which supplies are delivered are considered dirty and may harbor various infectious agents.
Where a staff changing area is provided for sterile processing staff, it shall be permitted to be shared with other staff in the same facility. See Section 2.1-3.9.4 (Staff Changing Area) for requirements.
Where sterile processing services are provided off-site, the following on-site support spaces shall be provided:
See Section 2.1-4.3.2.4 (2) (Clean/sterile medical/surgical supply receiving room or area) for requirements.
See Section 2.1-4.3.2.4 (1) (Instrument and supply storage) for requirements.
The soiled workroom described in Section 2.1-3.8.12 (Soiled Workroom or Soiled Holding Room) shall be permitted to serve this purpose.
Where linen is processed on-site, the following shall be provided:
  1. This area shall be large enough to accommodate the following:
    1. Washer
    2. Dryer
    3. Any plumbing equipment needed to meet the temperature requirements in Section 2.1-8.4.2.5 (4) (Water temperature)
  2. The area shall be divided into distinct soiled (sorting and washing) and clean (drying and folding) areas.
Storage for laundry supplies
Clean linen storage
Hand-washing station
Where linen is processed off-site, the following support areas shall be provided in the outpatient facility:
Soiled linen holding area or dedicated area for soiled laundry cart(s)
Clean linen storage area or dedicated area for clean linen cart(s)
Table 2.1-5
Classification of Room Types for Imaging Services1
Room Use Design Requirements2
Room Type Location Surfaces
Class 1 imaging room Diagnostic radiography, fluoroscopy, mammography, computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and other imaging services

Services that use natural orifice entry and do not pierce or penetrate natural protective membranes
Unrestricted area Accessed from an unrestricted area Flooring: cleanable and wear-resistant for the location; stable, firm, and slip-resistant

Wall finishes: washable

Ceiling: cleanable with routine housekeeping equipment; lay-in ceiling permitted
Class 2 imaging room Diagnostic and therapeutic procedures such as coronary, neurological, or peripheral angiography Electrophysiology procedures Semi-restricted area Accessed from an unrestricted or a semi-restricted area Flooring: cleanable and wear-resistant for the location; stable, firm, and slip-resistant

Floor and wall base assemblies: monolithic floor with integral coved wall base carried up the wall a minimum of 6 inches

Wall finishes: washable; free of fissures, open joints, or crevices

Ceiling: smooth and without crevices, scrubbable, non-absorptive, non-perforated; capable of withstanding cleaning chemicals; lay-in ceiling permitted if gasketed or each ceiling tile weighs at least one pound per square foot and no perforated, tegular, serrated, or highly textured tiles
Class 3 imaging room Invasive procedures3
Any Class 2 procedure during which the patient will require physiological monitoring and is anticipated to require active life support
Restricted area Accessed from a semi-restricted area Flooring: cleanable and wear-resistant for the location; stable, firm, and slip-resistant

Floor and wall base assemblies: monolithic floor with integral coved wall base carried up the wall a minimum of 6 inches

Wall finishes: washable; free of fissures, open joints, or crevices

Ceiling: monolithic, scrubbable, capable of withstanding cleaning and/or disinfecting chemicals, gasketed access openings
1This table includes a brief description of the imaging services performed in these room types and a summary of some applicable requirements that appear elsewhere in the 2018 Guidelines for Design and Construction of Outpatient Facilities. The table has been provided to help users determine when a Class 1, Class 2, or Class 3 imaging room is required for a project.
2Other design requirements that apply to these imaging room types include, but are not limited to, ventilation, lighting, and sound transmission requirements. See Part 3 (ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities) for ventilation requirements for these rooms. See Section 2.1-8.3.4.3 (Lighting for specific locations in outpatient facilities) and facility chapters for lighting requirements and Section 1.2-6.1 (Acoustic Design) for noise transmission requirements.
3"Invasive procedure" is defined in the glossary.
Use of shared or purchased materials management services shall be permitted as long as on-site handling and storage areas are provided to meet the facility's needs.
An unpacking or box breakdown area shall be accessible from the designated delivery door.
Where a service entrance is provided for loading and unloading of supplies, it shall be protected from inclement weather.
A2.1-5.2 Nuclear waste disposal. For information about handling and disposing of nuclear materials in health care facilities, see Code of Federal Regulations, Title 10, Part 20 (Standards for Protection Against Radiation) and Part 35 (Medical Use of Byproduct Material).
Locations shall be provided for waste collection and storage as identified during project planning.
  1. Locations for waste collection and storage shall meet local, state, and federal regulations.
  2. Where the following are provided in a facility, their locations shall be indicated in the design documents:
    1. Sharps disposal containers
    2. Compactor units (for municipal solid waste and recycling)
    3. Balers
    4. Recycling containers
  3. Waste collection and storage spaces for each of the following produced by the facility shall be indicated in the design documents:
    1. Municipal solid waste
    2. Regulated medical waste (RMW)
      1. Pharmaceutical waste (RCRA and non-RCRA)
      2. Anatomical remains
      3. Hazardous wastes
      4. Chemotherapy wastes (bulk and trace)
      5. Universal wastes
      6. Radiologic wastes
Size of spaces provided for waste collection and storage shall be based on the following:
  1. Categories and projected volume of waste
  2. Methods for handling and disposing of waste
  3. Length of anticipated storage
A2.1-5.2.1.2 The waste categories, handling and disposing methods, and length of storage should be identified during project planning.
(1)  Secured space shall be provided for regulated medical waste and other regulated waste types.
*(a) Where provided as interior spaces, areas for temporary holding of regulated waste shall have cleanable floor and wall surfaces.
(b) Where an exterior holding space is provided, it shall have the following:
(i)   Cleanable floor (and wall, where provided) surfaces
(ii)  Protection from weather
(iii) Protection from animals
(iv) Protection from vermin infestation
(2)  Such holding spaces shall provide:
(a) Illumination to a minimum of 50 foot-candles
(b) Protection from unauthorized entry
(3)  Refrigeration requirements for such holding facilities, if provided, shall comply with local and/or state regulations.
A2.1-5.2.1.3 (1)(a) Regulated waste includes medical waste, chemical hazardous waste (including universal wastes such as mercury-containing fluorescent light tubes), nuclear reagent waste, and other regulated waste types.
Where provided, refuse chutes shall meet the requirements of applicable codes and standards.
A2.1-5.2.1.4 The minimum cross-sectional dimension of gravity chutes should be as specified in NFPA 82: Standard on Incinerators and Waste and Linen Handling Systems and Equipment. For sprinkler protection information, refer to NFPA 13: Standard for the Installation of Sprinkler Systems.
  1. A minimum of one environmental services room per floor shall be provided.
  2. Additional environmental services room(s) shall be provided on a floor according to the needs of the areas served.
  3. An environmental services room shall be permitted to serve more than one clinical service area on the same floor.
A2.1-5.3.1.1 Environmental services room. Some departments or areas may need individually assigned environmental services rooms. Examples include:
  1. Clinical areas: Pre-procedure areas, examination rooms, blood draw areas, PACUs, dialysis treatment areas, infusion areas, endoscopy procedure rooms, or other areas likely to come into contact with blood or body fluids
  2. Sterile areas: Operating rooms, corridors in the semi-restricted area of the surgery suite, sterile labs, and sterile storage
  3. Processing rooms: Endoscope processing room (If these areas are in a sterile area, sanitation needs can be addressed procedurally, for example, by cleaning them last.)
  4. Public and administrative areas: Waiting areas, offices, and hallways
Each environmental services room shall be provided with the following:
(1)  Service sink or floor-mounted mop sink
*(2)  Provisions for storage of supplies and housekeeping equipment
(3)  Hand-washing station or hand sanitation dispenser
A2.1-5.3.1.2 Environmental services room features. Environmental services rooms should be planned to accommodate carts where carts are used in the housekeeping process.
A2.1-5.3.1.2 (2) If further storage areas for housekeeping supplies and equipment are needed, storage locations outside the environmental services room may be used.
Shared engineering services and maintenance facilities shall be permitted.
Equipment room(s) for HVAC equipment, telecommunications equipment, and electrical equipment shall be provided for the equipment included.
Mechanical and electrical equipment rooms shall be secured with controlled access.
A2.1-5.4.2.2 Additional information can be found in Security Design Guidelines for Healthcare Facilities, Section 02.08: Utility, Mechanical and Infrastructure Areas, published by the International Association for Healthcare Security & Safety (IAHSS).
A storage room(s) for building maintenance supplies and equipment shall be provided.
The following shall be provided:
A2.1-6.2.1 Roof overhang or canopy. Climate, patient acuity, and community standards may influence whether a covered or canopied entrance is desired. Where a roof overhang or canopy is provided, it should extend as far as practicable to the face of the driveway or curb of the passenger access door of the transport vehicle. Vehicles in the loading area should not block or restrict movement of other vehicles in the drive or parking areas immediately adjacent to the facility.
A minimum of one building entrance shall be reachable from grade level.
Building entrances used to reach outpatient services shall be clearly marked.
Building entrances used to reach outpatient services shall be located so patients need not go through other activity areas. (Shared lobbies shall be permitted in multi-occupancy buildings.)
A reception and information counter, desk, or kiosk shall be provided either at the main entry or at each clinical service.
A2.1-6.2.3 Waiting area or room
  1. Consideration should be given to the special needs of specific patient groups in a shared/general waiting area. This may result in provision of separate accommodations for elderly patients or other patients such as those with PTSD, pediatric designated areas, or sick or well rooms.
  2. Special attention should be paid to the path of travel to waiting areas or rooms for expanded-capacity wheelchairs. Further accommodations for persons of size are defined in Section 2.1-2 (Accommodations for Care of Patients of Size).
  3. Provision of wi-fi access for public use, including infrastructure to support it, should be considered.
The number and location of waiting area(s) or room(s) and associated seating needed to support the operational model of the health care organization shall be determined and designated in the project planning documents.
A2.1-6.2.3.1 Seating capacity for waiting areas or rooms. See appendix table A2.1-a (Waiting Area Seating Capacity) for recommendations. New operational models may require less seating or fewer waiting spaces in non-typical locations.
The waiting area shall be visible from a staff area, either by camera or direct staff sight line.
A2.1-6.2.3.2 Visual observation of waiting areas or rooms supports patient and staff safety.
Toilet room(s) for public use shall be readily accessible from the waiting area without passing through patient care or staff work areas.
Placement of public toilet room(s) off a public corridor in a multi-tenant building shall be permitted.
Access to make local phone calls shall be provided.
Access to drinking water shall be provided.
Where a wheelchair(s) owned by the health care organization is made available for patient use, a designated area located out of the required corridor width and directly accessible to the entrance shall be provided for at least one wheelchair.
If the facility provides services that require patients to transfer to a facility chair, wheelchair, recliner, examination table, or stretcher, a designated area shall be provided for parking at least one patient-owned wheelchair in a non-public area located out of any required egress width or other required clearance.
A2.1-6.2.7.2 Wheelchair parking. Facilities that provide a significant quantity of services to aging and disabled populations that use wheelchairs {e.g., dialysis patients) should provide more than one wheelchair parking space. Other facilities may be able to address the issue with scheduling and transportation procedures. Check with the authority having jurisdiction to determine if this is an acceptable alternative.
A2.1-6.3 Multipurpose room(s) should be provided for private interviews, conferences, meetings, and health education purposes. Where health education is accommodated, the room(s) should be equipped for audiovisual aids.
A2.1-6.3.2 Interview space. Such spaces may be used for patient communication/interviews related to social services, credit, etc.
Where provided, space(s) for private interviews shall be separate from public areas.
Shared use of an office or consultation room for this purpose shall be permitted.
Office space for business, administrative, and professional staffs shall be provided to support the services provided.
A2.1-6.3.3 The following types of employees/services are among those to be considered when determining the amount of office space needed:
  1. Owner/director
  2. Other supervisors
  3. Business office personnel
  4. Each type of health care professional employed by the facility
  5. Physicians (unique confidentiality duties may make private office space critical)
  6. Social work
  7. Maintenance
Provisions shall be made for securing medical records of all media types used by the facility.
To maintain confidentiality of records, the medical records area shall be restricted to staff access.
  1. Space shall be provided for medical records management.
  2. Physical space requirements for electronic storage of forms or documents shall be coordinated with electronic medical records personnel from the facility.
Storage for office equipment and supplies shall be provided.
A2.1-6.3.6 Storage areas for the following should be identified:
  1. Non-clinical records, documents, and reports
  2. Office supplies
  3. Decorations and furnishings
Where a staff lounge is provided, it shall include a hand-washing station.
Storage for staff personal effects (locking drawers, cabinets, or lockers) shall be readily accessible to individual work areas.
Building design and construction shall comply with local, state, and federal requirements.
A2.1-7.1 Outpatient occupancy classification. The outpatient facilities described in this document may be an outpatient unit in a hospital, a freestanding facility, or an outpatient facility in a multiple-use building. Occasional facility use by patients on stretchers should not be used as a basis for more restrictive institutional occupancy classifications.
  1. Corridor widths shall meet applicable life safety and building code requirements.
  2. Corridors used for stretcher and gurney transport shall have a minimum corridor or aisle width of 6 feet (1.83 meters).
A2.1-7.2.2.1 Corridor width. In areas where patient ambulation is encouraged or necessary for recovery, rest areas should be provided.
The minimum ceiling height shall be 7 feet 10 inches (2.39 meters), with the following exceptions:
*(1)  The minimum ceiling height in corridors and in normally unoccupied spaces shall not be less than 7 feet 6 inches (2.29 meters).
(2)  The minimum height above the floor of suspended tracks, rails, and pipes located in the traffic path shall be 7 feet 6 inches (2.29 meters).
A2.1-7.2.2.2 (1) Examples of normally unoccupied spaces are toilet, storage, changing, soiled holding, clean holding, environmental services, electrical, and information technology rooms and alcoves.
(1)  Door type
(a) All doors between corridors, rooms, or spaces subject to occupancy shall be of the swing type or shall be sliding doors.
*(b)  Sliding doors
(i)   Use of manual or automatic sliding doors shall be permitted where fire and other emergency exiting requirements are not compromised.
(ii) Sliding doors with emergency breakaway features in the full open position shall be permitted to temporarily restrict the minimum corridor width required by applicable building codes where approved by the authority having jurisdiction.
*(iii) Sliding doors in patient care areas shall not have floor tracks.
*(2)  Door openings
(a) Door openings serving occupiable spaces shall have a minimum clear width of 32 inches (81.28 centimeters).
(b) The minimum clear door opening for rooms where gurneys will be used shall have these dimensions:
*(i) 41.5 inches (1,054 millimeters) in width
(ii) 79.5 inches (2,019 millimeters) in height
(3)  Door swing
*(a) Doors shall not be permitted to swing into corridors except doors in behavioral health facilities and doors to non-occupiable spaces (e.g., environmental services rooms, electrical closets) and doors with emergency breakaway hardware.
(b) Doors shall be permitted to swing outward into an alcove that is deeper than the width of the door.
(c) A 180-degree door swing shall not be exempt from this requirement.
*(4)  Door hardware. Lever hardware or push/pull latch hardware shall be provided.
(5)  Doors for patient toilet rooms
(a) Door type. Rooms that contain a toilet for patient use shall have one of the following:
(i) A door that swings outward
*(ii) A door equipped with emergency rescue hardware
*(iii) A sliding door other than a pocket door
(b) Door opening. Where a toilet room opens onto a public area or corridor, visual privacy shall be maintained.
A2.1-7.2.2.3 Doors and door hardware. High-touch components of doors and hardware should be selected to suit the use of the space and the organization's cleaning protocols.
A2.1-7.2.2.3 (1)(b) Sliding doors. Use of sliding doors rather than swing doors is highly recommended for airborne infection isolation rooms and other spaces for which an ICRA has identified infection control as an issue. Research has shown that swinging door motion induces up to six times more possible contaminate than sliding door motion and can significantly affect contaminant control.
A2.1-7.2.2.3 (1)(b)(iii) Eliminating floor tracks and using breakaway door hardware minimizes the possibility of jamming.
A2.1-7.2.2.3 (2) Door openings-general
  1. The door opening sizes given are the minimum clear width and height.
  2. The clear width needed to accommodate access by patients and patient equipment has been taken into consideration in calculating the door opening dimensions given.
  3. Where patients are served who require patient handling and moving equipment and/or assistance, door openings should be sized for the equipment that will be used and the number of staff required to support patient safety.
A2.1-7.2.2.3 (2)(b)(i) The door opening specified here is intended for use with a gurney that is 30-32-inches (762-813 millimeters) wide. If wider gurneys are used, the clear door opening should be 44.5 inches (113 centimeters).
A2.1-7.2.2.3 (3)(a) The intent of this requirement is to avoid injury caused by outward-swinging doors.
A2.1-7.2.2.3 (4) Door protection should be provided where a door is subject to impact.
A2.1-7.2.2.3 (5)(a)(ii) Emergency rescue hardware. Emergency rescue hardware for toilet room doors permits easy access from outside the room to prevent blockage of the door.
A2.1-7.2.2.3 (5)(a)(iii) Use of sliding doors. Sliding doors are permitted for toilet rooms if they do not conflict with other requirements, such as handicapped accessibility, and cannot be blocked from the inside. A pocket type of sliding door would not meet this requirement because weight pushed up against this type of door prevents the door from opening for access from outside the room.
*(1)  General
(a) Hand sanitation dispensers and hand-washing stations shall be provided.
(b) The number and placement of both hand-washing stations and hand sanitation dispensers shall be determined by an ICRA.
(c) See Section 2.1-3.8.7 (Hand-Washing Station) and the facility chapters in Part 2 for information about locations where hand-washing stations are required.
(2)  Sinks. For basin, fitting, and anchoring requirements, see Section 2.1-8.4.3.2 (Hand-washing station sinks).
(3)  Hand-washing station countertops
(a) Hand-washing station countertops shall be made of porcelain, stainless steel, solid-surface materials, or plastic laminate assembly.
*(b)  For countertops that require a substrate, marine-grade plywood (or an equivalent material) with an impervious seal shall be required.
(4)  Where a hand-washing station includes casework, it shall be designed to prevent storage beneath the sink.
(5)  Provisions for drying hands. Single-use or disposable provisions for hand drying shall be required at all hand-washing stations except hand scrub facilities.
(a) Hand-washing stations shall include a hand-drying device that does not require hands to contact the dispenser.
(b) These provisions shall be enclosed to protect against dust or soil.
(c) Hot air dryers shall be permitted.
(d) Where provided, single-use towels shall be directly accessible to sinks.
(6)  Cleansing agents. Hand-washing stations shall include liquid or foam soap dispensers.
*(7)  Mirror. Mirrors shall be permitted at hand-washing sinks in public toilet rooms and in shower rooms.
A2.1-7.2.2.8 Consideration should be given to placement of electrical devices (space needed for work flow and placement away from the sink).
A2.1-7.2.2.8 (1) To avoid confusion between soap and alcohol-based hand rubs, alcohol-based hand-rub dispensers should not be placed adjacent to sinks and soap dispensers.
A2.1-7.2.2.8 (3)(b) Hand-washing station countertops
  1. The presence of water around hand-washing sinks has consistently proven to encourage the presence of mold and bacteria in the substrate materials if the countertops are not properly sealed and maintained. Integral backsplashes eliminate intersections that need to be caulked.
  2. Under-mount basins are difficult to clean, and their use is discouraged.
A2.1-7.2.2.8 (7) Mirrors should not be used at clinical hand-washing stations to avoid personal grooming that can impact proper hand hygiene.
  1. Grab bars shall be anchored to sustain a concentrated load of 250 pounds (113.40 kilograms).
  2. Grab bars in toilet rooms intended for use by persons of size shall be anchored to sustain a concentrated load of 800 pounds (362.87 kilograms).
  3. Ends of grab bars shall be constructed to prevent snagging the clothes of patients, staff, and visitors.
A2.1-7.2.2.9 Grab bars
  1. Grab bars should have a finish that contrasts with the adjacent wall surface and provides slip resistance.
  2. Grab bars in patient toilet rooms should allow patients to be as safe and independent as possible. This includes using drop-down grab bars when needed, with or without integral toilet paper holder.
  3. Grab bars in patient toilet rooms should allow staff to complete a double transfer. To make this possible, the relationship between the toilet, wall, and grab bars should be evaluated. Clearance on both sides of the toilet is needed for a double transfer. Wall-mounted bars that fold up are the preferred solution because they leave space to facilitate cleaning and patient transfer. Floor-mounted grab bars can be used but are not preferred because of increased difficulty in cleaning and patient transfer. Seat-mounted grab bars are not recommended.
  1. Where provided, handrails shall comply with local, state, and federal requirements referenced in Section 1.1-4.1 (Design Standards for Accessibility) as amended in this section.
  2. Rail ends shall return to the wall or floor.
  3. Handrail gripping surfaces and fasteners shall be smooth (free of sharp or abrasive elements) with a 1/8-in. (3.18-millimeter) minimum radius.
  4. Handrails shall have eased edges and corners.
  5. Handrail finishes shall be cleanable.
A2.1-7.2.2.10 Handrails should be provided to assist mobility-impaired persons.
Radiation protection for x-ray and gamma ray installations shall conform with the following National Council on Radiation Protection & Measurements (NCRP) reports and local, state, and federal codes and standards.
  1. Report No. 102: Medical X-Ray, Electron Beam and Gamma-Ray Protection for Energies Up to 50 MeV (Equipment Design, Performance and Use)
  2. Report No. 147: Structural Shielding Design for Medical X-Ray Imaging Facilities
  3. Report No. 151: Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities
Rooms containing heat-producing equipment (e.g., boilers, heaters) shall be insulated to prevent the temperature in adjacent rooms from falling outside the intended design parameters for those room types.
  1. Installation of indoor, unsealed (open) water features shall not be permitted in the confines of the licensed outpatient health care occupancy area.
  2. Covered fish tanks shall be permitted in public areas of the licensed outpatient health care occupancy area.
A2.1-7.2.2.14 Fountains and other open decorative water features can represent a reservoir for opportunistic human pathogens.
(1)  Flooring surfaces shall be cleanable and wear-resistant for the location.
(2)  The use of carpeting in patient care areas and clinical support areas (e.g., labs and pharmacies) shall be permitted when approved as part of the infection control risk assessment (ICRA) process.
*(3)  Smooth transitions shall be provided between different flooring materials.
(4)  Flooring surfaces, including those on stairways, shall be stable, firm, and slip-resistant.
*(a) The slip-resistance ratings of flooring surfaces shall be appropriate for the area of use-for dry or wet conditions and for use on ramps and slopes.
(b) Carpet with or without padding shall be installed so it provides a stable and firm surface.
(5)  The floors and wall bases of all areas subject to frequent wet cleaning shall be constructed of materials that are not physically affected by germicidal or other types of cleaning solutions.
(6)  Floor and wall base assemblies
(a) The room types listed in this section shall have floor and wall base assemblies that are monolithic and have an integral coved wall base that is carried up the wall a minimum of 6 inches (150 mm) and is tightly sealed to the wall.
(i) Operating room
(ii) Class 2 and Class 3 imaging rooms
(iii)  Procedure rooms where cystoscopy, urology, and endoscopy procedures are performed
(iv)  Endoscope processing room
(v)   IV and chemotherapy preparation rooms
(vi)  Airborne infection isolation (AII) room
(vii) Anteroom to AII room, where provided
(viii) Sterile processing facility
*(b)  Equipment shall be permitted to penetrate these monolithic floors provided joints are sealed and do not represent a tripping hazard.
(7)  Floor openings for pipes, ducts, and conduits as well as joints at structural elements shall be tightly sealed.
A2.1-7.2.3.1 Flooring
  1. The patient handling and movement assessment and the fall prevention assessment portions of the safety risk assessment should be consulted when choosing flooring materials; see sections 1.2-4.3 (Patient Handling and Movement Assessment) and 1.2-4.4 (Fall Prevention Assessment).
    • -Balancing the softness (non-rigid properties) and firmness of a flooring material is a key consideration for supporting maintenance of gait, postural stability, and balance; reducing fatigue and falls; and facilitating movement of wheelchairs and other wheeled traffic.
    • -The subfloor, the composition of a flooring material, and the material's ability to yield to pressure should be considered when selecting flooring that can contribute to force attenuation when a fall does occur.
  2. The evidence associated with identification of single environmental variables and their importance in preventing, attenuating, or exacerbating patient falls is still emerging. A number of studies in which multiple variables were studied have suggested an association between falls and the following flooring materials and characteristics:
    • -Flooring. Some flooring types (e.g., carpet, resilient flooring such as rubber, VCT, sheet vinyl) can be a trip hazard.
    • -Floor pattern. Some studies suggest that flooring with a medium-sized pattern (1—6 inches wide) were associated with more falls than floors with no pattern, a small pattern (less than 1 inch wide), or a large pattern (wider than 6 inches).
    • -Floor contrast. High-contrast patterns on floor surfaces may be associated with more patient falls.
    • -Floor reflectivity. Finished floors with a high gloss value cause glare that may compromise patient vision, disrupting balance. The selection of non-wax flooring eliminates finish glare. Where a finish coat is required, smooth flooring surfaces should be sealed with a matte finish to reduce surface glare.
    • -Wall and floor color contrast. Color contrast between walls and floors and minimized transitions between different types of flooring may reduce falling risk.
    • -Floor acoustic properties. Floors should be selected with consideration to acoustic properties to help preserve sleep and to protect privacy and accuracy of communication in support of HIPAA compliance and medical error reduction. See sections 1.2-6.1.3 (Design Criteria for Acoustic Surfaces) and 1.2-6.1.6 (Design Guidelines for Speech Privacy).
  3. Floor resistance. Floor surfaces should allow easy movement of all wheeled equipment to be used in the facility. Portable lifting equipment without powered wheels may require more exertion by staff than ceiling-mounted equipment to move an elevated patient around and through a space. The exertion required by staff may increase with the use of carpet; however, different types and brands of carpet may have significantly different levels of resistance to wheeled devices. Installation of a mock-up to test flooring materials in relationship to wheeled equipment and devices used in a facility is recommended. Carpet should not be automatically discounted as inappropriate due to this challenge as it has major advantages over hard-surface flooring in terms of acoustic properties.
A2.1-7.2.3.1 (3) Flush thresholds should be used to reduce tripping hazards.
A2.1-7.2.3.1 (4)(a) Wet conditions are common in areas such as kitchens and bathing areas, entries from exterior to interior space, and areas where water is used for patient services. Slip resistance is also an important consideration for ramps and stairways. In dry areas, soft flooring (e.g., carpet, cushioned flooring, etc.) can be used to reduce the risk of falls and the impact of associated injuries.
A2.1-7.2.3.1 (6)(b) Equipment that is fastened to the monolithic floor requires sealed joints at the fastening points to prevent fluids from penetrating the subfloor. Where infrastructure items such as floor ducts to accommodate electrical cabling are installed, the duct cover needs to be sealed to prevent fluids from entering the floor duct.
  1. Wall finishes
    1. Wall finishes shall be washable.
    2. Wall finishes in the vicinity of plumbing fixtures shall be:
      1. Smooth
      2. Scrubbable
      3. Water-resistant
    3. Wall finishes in the room types listed shall be free of fissures, open joints, or crevices that may retain or permit passage of dirt particles:
      1. Operating and procedure rooms
      2. Class 2 and Class 3 imaging rooms
      3. Endoscopy procedure room
      4. Endoscope processing room
      5. IV and chemotherapy preparation room
      6. Airborne infection isolation (AII) room
      7. Anteroom to AII room, where provided
      8. Sterile processing facility
  2. Wall surfaces in areas routinely subjected to wet spray or splatter (e.g., kitchens, environmental services rooms, etc.) shall be monolithic or have sealed seams that are tight and smooth.
  3. Wall openings for pipes, ducts, and conduits as well as joints at structural elements shall be tightly sealed.
  4. Wall protection devices and corner guards shall be durable and scrubbable.
A2.1-7.2.3.2 Sharp, protruding corners should be avoided.
(1)  Ceilings shall be provided in all areas except as noted in Section 2.1-7.2.3.3 (4) (Mechanical, electrical, and communications equipment rooms).
(a) Ceilings shall be cleanable with routine housekeeping equipment.
(b) Acoustic and lay-in ceilings, where used, shall not create ledges or crevices.
*(2)  Semi-restricted areas
(a) Ceiling finishes in semi-restricted areas shall be:
(i)  Smooth and without crevices
(ii) Scrubbable
(iii) Non-absorptive
(iv) Non-perforated
(v) Capable of withstanding cleaning with chemicals
(b) Where a lay-in ceiling is provided, it shall be gasketed or each ceiling tile shall weigh at least one pound per square foot.
(c) Use of perforated, tegular, serrated, or highly textured tiles shall not be permitted in semi-restricted areas.
*(3)  Restricted areas
(a) Ceilings in restricted areas shall be of monolithic construction.
(i)   Cracks or perforations in these ceilings shall not be permitted.
*(ii)  The central diffuser array shall not be considered part of a monolithic ceiling.
(b) Ceiling finishes shall be scrubbable and capable of withstanding cleaning and/or disinfecting chemicals.
(c) All access openings in ceilings in restricted areas shall be gasketed.
(4)  Mechanical, electrical, and communications equipment rooms. Omission of suspended ceilings in these rooms or spaces shall be permitted unless required for fire safety purposes.
A2.1-7.2.3.3 (2) Semi-restricted areas. These include areas such as procedure rooms, Class 2 imaging rooms, endoscope processing rooms, decontamination rooms, clean corridors, and central sterile supply.
A2.1-7.2.3.3 (3) Restricted areas. These include areas such as operating rooms, Class 3 imaging rooms, and sterile compounding and hazardous drug compounding pharmacies.
A2.1-7.2.3.3 (3)(a)(ii) Central diffuser array. A central diffuser array consisting of unidirectional flow diffusers and/or architectural fill-in panels should form a single assembly in the ceiling. The array should be gasketed between the diffuser array system and the ceiling and also between the system framing and the individual diffusers. Where booms and other equipment are located in the central diffuser array, the array should be provided with fill-in panels cut to accommodate the booms or other equipment. Fill-in panels are to be gasketed at the framing and at the perimeter of any cuts made to accommodate the equipment.
A2.1-7.2.4 Work areas. Where a work space, work area, work counter, or work surface is provided, it should have a minimum of 4 square feet (.37 square meter) of contiguous clear surface for each person programmed to work in the space at the same time.
  1. Blinds, sheers, or other window treatments shall be provided to allow for patient privacy and to control light levels and glare in patient care areas.
  2. Window treatments shall not compromise patient safety and shall be easy for patients, visitors, and staff to operate.
  3. Window treatments shall be selected for ease of cleaning, disinfection, or sanitization.
  4. Use of fabric drapes and curtains for window treatments shall be permitted if the fabric is washable.
Use of fabric privacy curtains shall be permitted if the fabric is washable.
The following facility types shall comply with Part 3 (ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities):
  1. Outpatient surgery facilities
  2. Endoscopy facilities
For the following facility types, room types listed in Table 8.1 of ANSI/ASHRAE/ASHE Standard 170 shall meet the requirements of Standard 170:
  1. Imaging facilities with Class 2 and 3 imaging rooms
  2. Infusion centers
  3. Renal dialysis centers
A2.1-8.2.1.2 Individual spaces used for imaging, infusion, and dialysis services that are listed in Table 8.1 in Standard 170 are treated the same as a space in a licensed facility and have the same HVAC requirements. Spaces with space names not listed in Table 8.1 need not comply with Standard 170.
For other outpatient facility types, HVAC systems shall meet state and local building code requirements.
See Section 8.2 in the following chapters for additional HVAC information.
Chapter 2.12, Specific Requirements for Outpatient Rehabilitation Facilities
Chapter 2.13, Specific Requirements for Mobile/Transportable Medical Units
A2.1-8.3.1 Power disturbance safeguards. Data processing and/or automated laboratory or diagnostic equipment, where provided, may require safeguards from power line disturbances. Where the equipment vendor does not provide power disturbance safeguards, other protection may be required (e.g., UPS with filtration).
  1. All electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of:
    1. NFPA 70: National Electrical Code®
    2. NFPA 99: Health Facilities Code
  2. All electrical material and equipment shall be listed as complying with available standards of listing agencies or other similar established standards where such standards are required.
  1. Location. Switchboards, switchgear, and automatic transfer switches shall be:
    1. Located in a room that meets the requirements of NFPA 70: National Electrical Code®.
    2. Accessible to authorized persons only.
    3. Located in dry, ventilated spaces free of corrosive or explosive fumes or gases or any flammable material.
  2. Overload protective devices shall be listed for the ambient room temperature for the space in which they are installed.
  1. All panelboards shall be accessible to the health care tenants they serve.
  2. Where panelboards serving critical branch circuits are required, they shall be located on each floor where services are provided.
  3. Where panelboards serving life safety branch circuits are required, they shall be permitted to serve floors immediately above and/or immediately below the level where the panel is located.
  4. New panelboards shall not be located in exit enclosures or exit passageways.
  1. Ground-fault circuit interrupters (GFCIs) shall comply with NFPA 70: National Electrical Code®.
  2. Where GFCIs are used in critical care areas, each receptacle shall be individually protected by a single GFCI device.
  1. Where required by NFPA 99, an essential electrical system shall be provided in the outpatient facility.
  2. Where required by NFPA 99, emergency electrical power shall be provided in the outpatient facility.
  3. The following codes shall be consulted for requirements:
    1. NFPA 70: National Electrical Code®
    2. NFPA 99: Health Care Facilities Code
    3. NFPA 101: Life Safety Code®
    4. NFPA 110: Standard for Emergency and Standby Power Systems
    5. NFPA 111: Standard on Stored Electrical Energy Emergency and Standby Power Systems
A2.1-8.3.3.1 Local, state, and federal requirements may demand provision of emergency power for some outpatient facility types.
A2.1-8.3.4 Required levels for artificial illumination in health care facilities should comply with Illuminating Engineering Society (IES) publication ANSI/IES RP-29: Recommended Practices for Lighting for Hospitals and Healthcare Facilities. Light intensity for staff and patient needs should generally comply with these IES guidelines. Consideration should be given to controlling intensity and/or wavelength to prevent harm to the patient's eyes (i.e., retina damage to premature infants and cataracts due to ultraviolet light).
Many means are available to satisfy lighting requirements, but the design should consider light quality as well as quantity for effectiveness and efficiency. While light levels in the IES publications are referenced herein, those publications include other useful guidance and recommendations which the designer is encouraged to follow.
Where special lighting needs for the elderly are required, they shall be incorporated into the lighting design.
A2.1-8.3.4.1 Refer to ANSI/IES RP-28: Recommended Practices for Lighting and the Visual Environment for Seniors and the Low Vision Population.
(1)  Exam/treatment/trauma rooms. A portable or fixed examination light shall be provided for examination, treatment, and trauma rooms.
(2)  Operating rooms
(a) Operating rooms shall have general lighting in addition to special lighting units provided at surgical tables.
(b) General lighting and special lighting shall be on separate circuits.
(3)  Medication safety zone work areas and pharmacy areas. See Section 2.1-3.8.8.1 (2)(d) (Medication safety zones: Design requirements-Lighting) for lighting requirements for medication safety zones and pharmacy areas.
*(4)  Uplight or trough lighting fixtures installed in patient care areas shall be covered.
A2.1-8.3.4.3 Lighting for medication safety zone work areas. Detailed lighting recommendations for medication safety zone work areas, including those in pharmacies, can be found in USP-NF General Chapter <1066>, "Physical Environments That Promote Safe Medication Use."
A2.1-8.3.4.3 (4) Using a translucent cover, such as a lens, prevents dust from getting into the fixture and facilitates cleaning of the top of the fixture.
A2.1-8.3.5 Electronic health record system servers and centralized storage. To prevent data loss during transition between normal and emergency power, the health care organization should consider providing an uninterruptible power supply (UPS) or other means of preventing data loss for electronic health record equipment, which may include order entry systems.
Where an essential electrical system is provided, any required hand-washing station or scrub sink that depends on the building electrical service for operation shall be connected to the essential electrical system.
Fixed and mobile x-ray equipment installations shall conform to articles 517 and 660 of NFPA 70.
At locations where anesthetic is administered, all electrical equipment and devices, receptacles, and wiring shall comply with applicable sections of NFPA 99 and NFPA 70.
Receptacles in patient care areas shall be provided according to Table 2.1-1 (Electrical Receptacles for Patient Care Areas in Outpatient Facilities).
A2.1-8.3.6 Height of electrical receptacles. Potential high-use electrical receptacles in patient care areas (e.g., those areas proximal to gurneys and exam tables) should be positioned a minimum of 30 inches (76.2 centimeters) above finished floor (AFF) to the center of the electrical outlet. This height is recommended to minimize the need for staff to bend over to reach the receptacles.
Unless otherwise specified herein, all plumbing systems shall be designed and installed in accordance with the locally adopted plumbing code.
  1. All piping, except control-line tubing, shall be identified.
  2. All valves shall be tagged, and a valve schedule shall be provided to the facility owner for permanent record and reference.
  3. No plumbing piping shall be exposed overhead or on walls where possible accumulation of dust or soil may create a cleaning problem or where leaks would create a potential for food contamination.
(1)  Capacity
(a) Systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand.
(b) Supply capacity for hot- and cold-water piping shall be determined on the basis of fixture units, using recognized engineering standards.
(c) Where the ratio of plumbing fixtures to occupants is proportionally more than required by the building occupancy and is in excess of 1,000 plumbing fixture units, use of a diversity factor to calculate capacity is permitted.
*(2)  Valves. Each water service main, branch main, riser, and branch to a group of fixtures shall have shutoff valves.
(a) Shutoff valves shall be provided for each fixture.
(b) Access shall be provided for all valve locations.
(3)  Backflow prevention, where required by local codes or medical equipment manufacturers
(a) Systems shall be protected against cross-connection in accordance with AWWA M14: Backflow Prevention and Cross-Connection Control: Recommended Practices.
(b) Vacuum breakers or backflow prevention devices shall be installed on hose bibs and supply nozzles used for connection of hoses or tubing in laboratories, housekeeping sinks, etc.
(4)  Potable water storage vessels (hot and cold) not intended for constant use shall not be installed.
A2.1-8.4.2.3 (2) Valves
  1. Provision of shutoff valves to groups of fixtures is intended to allow just part of a plumbing system to be closed for repair rather than a whole floor or building.
  2. Where a reduced pressure zone valve is hooked up to a clinical device (e.g., an AER, or automated endoscope reprocessor), the reduced pressure zone after the valve should have a design feature that allows for automatic flushing of chlorinated water.
(1)  Provisions based on a risk management plan shall be included in the heated potable water system to limit the amount of Legionella bacteria and other opportunistic waterborne pathogens.
(2)  Heated potable water distribution systems serving patient care areas shall be under constant recirculation to provide continuous hot water at each hot water outlet. Non-recirculated fixture branch piping shall not exceed 25 feet (7.62 meters) in length.
(3)  Elimination of dead-end piping
(a) Installation of dead-end piping (risers with no flow, branches with no fixture) shall not be permitted.
(b) In renovation projects, dead-end piping shall be removed.
(c) Installation of empty risers, mains, and branches for future use shall be permitted.
*(4)  Water temperature
*(a) The water-heating system shall supply water at the following range of temperatures: 105—120°F (41—49°C). Storage of water at higher temperatures shall be permitted.
*(b)  For hand-washing stations, water shall be permitted to be supplied at a constant temperature between 70°F and 80°F using a single-pipe supply. For showers and other end-use devices requiring heated water, water shall be permitted to be supplied by this low-temperature circulation system and heated with point-of-use heaters.
A2.1-8.4.2.5 Heated potable water distribution systems
  1. Legionella response. For information about addressing Legionella, see the CDC "Guidelines for Environmental Infection Control in Health-Care Facilities," ASHRAE Standard 188: Legionellosis: Risk Management for Building Water Systems, and ASHRAE Guideline 12: Minimizing the Risk of Legionellosis Associated with Building Water Systems. Another reference on this topic is "Legionella Control in Health Care Facilities," available from the American Society of Plumbing Engineers.
    Although immunocompromised patients who may be at risk for Legionella or other opportunistic waterborne pathogens are not typically seen in outpatient facilities, facilities that serve immunocompromised patients may need to treat heated potable water distribution systems to minimize the risk of Legionella and other opportunistic waterborne pathogens.
  2. Design for efficient heated potable water distribution. Hot water distribution systems should be designed to deliver hot or tempered water in a "reasonable" time. Low-flow faucets, longer pipe runouts between a recirculated main and the fixture, and larger diameter pipes increase the time it takes to achieve desired temperatures. Given the water conservation benefits of low-flow faucets, the design should consider either reducing the length of uncirculated runouts, reducing the pipe size, providing heat tracing for the runout, or using point-of-use water heaters. Following is a guide that may be used in designing a system based on delivery time.
    • -Design method. Hot and tempered water distribution systems should be designed using either the maximum pipe length or maximum pipe volume limits provided in this appendix section and appendix table A2.1-b (Maximum Length of Hot Water System Pipe or Tube). For purposes of this discussion, references to pipe should also apply to tubing and the source of hot or tempered water is considered to be a water heater, boiler, circulation loop piping, or electrically heat-traced piping.
      • • Maximum allowable pipe length method. The maximum allowable pipe length from the source of hot or tempered water to the termination of the fixture supply pipe should be in accordance with the maximum pipe length columns in appendix table A2.1-b. Where the length contains piping of more than one size, the largest pipe size should be used to determine the maximum allowable pipe length in the table.
      • • Maximum allowable pipe volume method. The maximum volume of hot or tempered water in hot water distribution piping should be calculated in accordance with the guidance just below. The maximum volume in piping to public hand-washing stations, metering or non-metering, should be 2 ounces (0.06 L). For fixtures other than those at public hand-washing stations, the maximum volume should be 64 ounces (1.89 L) for hot or tempered water from a water heater or boiler and 24 ounces (0.7 L) for hot or tempered water from a circulation loop pipe or an electrically heat-traced pipe.
    • -Water volume determination. The volume should be the sum of the internal volumes of pipe, fittings, valves, meters, and manifolds between the source of the hot water and the termination of the fixture supply pipe. The volume should be determined from the liquid ounces per foot column of appendix table A2.1-b. The volume contained in fixture shutoff valves, flexible water supply connectors to a fixture fitting, or a fixture fitting should not be included in the water volume determination. Where hot or tempered water is supplied by a circulation loop pipe or an electrically heat-traced pipe, the volume should include the portion of the fitting on the source pipe that supplies water to the fixture.
    • -Maximum flow rate. The maximum flow rate of fixtures should be limited to 0.5 gpm when connected to 1/4-inch piping, 1 gpm when connected to 5/16-inch piping, and 1.5 gpm when connected to 3/8-inch piping.
A2.1-8.4.2.5 (4) Water temperature is measured at the point of use or inlet to the equipment.
A2.1-8.4.2.5 (4)(a) To prevent scalding, it is recommended that water temperature at hand-washing stations and showers be limited by an ASSE 1070: Performance Requirements for Water Temperature Limiting Devices or equivalent device.
A2.1-8.4.2.5 (4)(b) One way to limit the potential growth of Legionella in a heated potable water system is to distribute water at a temperature of less than 80°F (26.6°C) for hand-washing use. Water at this temperature may be warm enough to encourage good hand-washing practice but cooler than the ideal growth conditions for Legionella.
(1)  Piping
*(a) Where drainage piping is installed above the ceiling of, or exposed in, operating rooms, procedure rooms, sterile processing facilities, Class 2 and 3 imaging rooms, electronic mainframe rooms, main switchgear and electrical rooms, and electronic data processing areas, the piping shall have special provisions (e.g., double-wall containment piping) to protect the space below from leakage and condensation.
(b) Where a drip pan is used to meet this requirement, it shall be accessible and have an overflow drain with a labeled outlet located in a normally occupied room or area that is not open to a restricted area.
(2)  Floor drains
(a) Floor drains shall not be installed in procedure, Class 2 and 3 imaging, and operating rooms with the following exception:
(b) Where a floor drain is installed in a dedicated cystoscopy procedure room, it shall contain a nonsplash, horizontal-flow flushing bowl beneath the drain plate that empties into a non-flushing drain with automatic trap primer.
(3)  Plaster traps
(a) Where a sink is used for disposal of plaster of paris, a plaster trap shall be provided.
(b) Where plaster traps are used, provisions shall be made for access and cleaning.
A2.1-8.4.2.6 (1)(a) Placement of plumbing piping over these spaces is not a good practice, but in some situations it may be unavoidable.
  1. Condensate drains for cooling coils shall be a type that may be cleaned as needed without disassembly.
  2. An air gap shall be provided where condensate drains empty into building drains.
  3. Heater elements shall be provided for condensate lines in freezers or other areas where freezing may be a problem.
  1. Materials. The material used for plumbing fixtures shall be non-absorptive and acid-resistant.
  2. Clearances. Water spouts used in sinks shall have clearances adequate to avoid contaminating utensils and the contents of carafes, etc.
*(1)  Sinks in hand-washing stations shall be designed with basins that will reduce the risk of splashing to areas where direct patient care is provided, sterile procedures are performed, and medications are prepared.
(2)  The sink basin shall have a nominal size of no less than 144 square inches (929.03 square centimeters), with a minimum dimension of 9 inches (22.86 centimeters) in width or length.
(3)  Hand-washing station sink basins shall be made of porcelain, stainless steel, or solid-surface materials.
(4)  Sink basins shall be installed so they fit tightly against the wall or countertop and sealed to prevent water leaks.
(5)  The water discharge point of hand-washing sink faucets shall be at least 10 inches (25.4 centimeters) above the bottom of the basin.
(6)  The water pressure at the fixture shall be regulated.
*(7)  Anchoring. For hand-washing station sinks, allowable stresses shall not be exceeded at any point on the sink where a vertical or horizontal force of 250 pounds (1112N) is applied.
(8)  Fittings. Hand-washing station sinks used by medical and nursing staff, patients, and the public shall have fittings that can be operated without using hands.
(a) Single-lever or wrist-blade devices. Use of these devices shall be permitted.
(i)   Blade handles used for this purpose shall be at least 4 inches (10.2 centimeters) in length.
(ii)  The location and arrangement of fittings shall provide the clearance required for operation of blade-type handles.
(b) Sensor-regulated water fixtures
(i)   These fixtures shall meet user need for temperature and length of time the water flows.
(ii)  Electronic faucets shall be capable of functioning during loss of normal power.
(iii) Use of sensor-regulated faucets with manual temperature control shall be permitted.
A2.1-8.4.3.2 Design of sinks should accommodate ADA requirements for clearance under the sink basin. Plumbing lines under hand-washing stations should be protected from damage caused by wheelchairs. See Section 2.1-7.2.2.8 (Architectural Details-Hand-washing stations) and 2.1-8.3.5.1 (Electrical Equipment-Hand-washing station sinks and scrub sinks) for further information.
A2.1-8.4.3.2 (1) Splashing should be prevented on surfaces where patient procedures are performed, medications are prepared, or sterile supplies are located. Recommendations for minimizing splashing through hand-washing station design and sink style include the following:
  1. Faucets should not discharge directly above the drain as this causes splashing (i.e., water should be angled away from the drain).
  2. Sink size and depth should follow ANSI standards for sink design.
  3. Water pressure should be adjusted to reduce forceful discharge into the sink at maximum flow.
A2.1-8.4.3.2 (7) Anchoring. See ICC/ANSI A117.1: Accessible and Usable Buildings and Facilities for more information.
  1. Shower units and tubs shall have nonslip surfaces.
  2. If provided, soap dishes shall be recessed.
Copper tubing shall be provided for supply connections to ice-making equipment.
  1. Clinical sinks shall be trimmed with valves that can be operated without hands.
    1. Single-lever or wrist blade devices shall be permitted.
    2. Handles on clinical sinks shall be at least 6 inches (15.24 centimeters) long.
  2. Clinical sinks shall have an integral trap wherein the upper portion of the water trap provides a visible seal.
  1. Freestanding scrub sinks shall be trimmed with foot, knee, or electronic sensor controls.
  2. Single-lever wrist blades shall not be permitted except for the temperature pre-set valve.
Quick-drench emergency deluge shower and face and eyewash devices shall be provided where required by the following:
*(1)  OSHA 29 CFR 1910: Occupational Safety and Health Standards
(2)  ANSI/ISEA Z358.1: American National Standard for Emergency Eyewash and Shower Equipment
A2.1-8.4.3.8 (1) OSHA standards
  1. OSHA 29 CFR 1910.151(c) (Medical Services and First Aid)
  2. OSHA 29 CFR 1910.1048 (i)(2) and (i)(3) (Formaldehyde)
  1. A dedicated drain shall be provided where portable hydrotherapy units are used.
  2. Hand-washing sinks shall not be used as drains for hydrotherapy units.
Station outlets shall be provided as indicated in Table 2.1-2 (Station Outlets for Oxygen, Vacuum, Medical Air, and Instrument Air Systems in Outpatient Facilities).
Where piped medical gas is used, the installation, testing, and certification of nonflammable medical gas and air systems shall comply with the requirements of NFPA 99: Health Care Facilities Code.
Where a central clinical vacuum system is provided, design and installation shall be in accordance with NFPA 99.
Nurse call stations shall be provided as required in Table 2.1-3 (Locations for Nurse Call Devices in Outpatient Facilities).
The requirements in this section shall be applied to outpatient facilities in freestanding buildings or a portion of a building with a separate occupancy classification.
A2.1-8.5.2 Telecommunications and information system requirements. Provision of these spaces should be considered for outpatient facilities located in a suite in a multi-tenant building (e.g., medical office buildings, outpatient surgery facilities, emergency facilities outside a hospital).
Locations for terminating telecommunications and information system devices shall be provided.
A central equipment space shall be provided that meets the following manufacturer requirements:
  1. Temperature range
  2. Air filtration
  3. Humidity control
  4. Voltage regulation
All health care facilities shall be provided with a fire alarm system in accordance with NFPA 101: Life Safety Code and NFPA 72: National Fire Alarm and Signaling Code.
Where an outpatient facility is located on more than one floor or on a floor other than an entrance floor at grade level, at least one elevator shall be provided.
Where outpatients are expected to be transported between different levels on gurneys, such as in facilities with operating rooms and recovery rooms on different floors, elevator cars shall have a minimum inside floor dimension of 5 feet 8 inches (1.73 meters) wide by 7 feet 9 inches (2.36 meters) deep.
Elevators shall be equipped with a two-way automatic level-maintaining device with an accuracy of ±1/4 inch (±6.35 millimeters).
Elevator call buttons and controls shall not be activated by heat or smoke.
Light beams, if used for operating door reopening devices without touch, shall be used in combination with door-edge safety devices and shall be interconnected with a system of smoke detectors.
A2.1-8.7.5.2 Use of light beams requires door-edge safety devices and smoke detectors so the light control feature will be overridden or disengaged should it encounter smoke at any landing.