Wiring 911

What does an electrician working in a health care facility — either as an employee or as a contractor — need to know so that he doesn't jeopardize the safety and safe treatment of the patients, staff, and visitors of the facility as a whole? Although the work of an electrician is generally limited to electrical circuits, the impact of his or her work reaches far beyond the normal electrical distribution system.

Because there are no degree-granting institutions offering a formal program in “Health Care Electricians” (at least not to the author's knowledge), this article outlines many of the issues an electrician needs to study, understand, and practice when he or she steps inside a health care facility.

The work environment

The work environment of an in-house electrician, or one hired by the medical facility, can be divided into three major areas:

The electrical shop,
Non-patient care areas, and
Patient care areas.

As you'll learn, these areas are not mutually exclusive — each involves the use of both general electrical items and equipment as well as health care-related electrical items and equipment.

The electrical shop — Whether it's located in a health care facility or at a company doing work for health care facilities, the electrical shop needs to stock the usual items and equipment to work on any electrical distribution system (e.g., receptacles, switches, voltmeters, pliers, protective clothing) as well as health care-related items.

Some of these items can be used anywhere; others may be required specifically for patient care areas. For example, you can install fluorescent lamps and junction boxes anywhere. On the other hand, hospital-grade receptacles and isolated power systems are required in certain patient care areas.

With respect to tools, some may have to be kept “clean” in order to be used in certain patient care areas. Others may have to be made of non-ferrous metal because of their use in or around MRI installations. One health care-related tool is referred to as a tension tester, a device used to measure the amount of effort required to remove an electric cord-cap (i.e., plug) from a receptacle. This device was developed after one of the NFPA health care Facilities Technical Committees established the amount of tension that the ground of a receptacle should exhibit when a cord-cap is removed from a receptacle. This requirement was intended to apply only to receptacles installed in patient care vicinities.

If some items stored in the electrical shop present a health, fire, or instability hazard, a sign, in accordance with NFPA 704, needs to be posted.

Non-patient areas — In a health care facility, what constitutes a non-patient area? And are there any special precautions a health care electrician needs to observe when working in these areas? The answer to these questions can be found in the following definition, developed for NFPA 99 for the term “patient care area”: “Any portion of a health care facility wherein patients are intended to be examined or treated.”

There is also a note in the appendix of the document, stating: “Business offices, corridors, lounges, day rooms, dining rooms, or similar areas typically are not classified as patient care areas.” The words “are intended” were deliberately added to make sure requirements for patient care areas weren't applied everywhere, considering the fact that a patient might be treated almost anywhere in an emergency.

Thus, any area that does not meet this definition is a non-patient area. But be careful: Many of these non-patient areas can be located very near a patient care area. Work being done in a non-patient area could affect the electrical system in a nearby patient care area(s). Therefore, it's very important for a health care electrician to know if the work he or she is doing in a non-patient care area affects a patient care area. For example, a corridor in a patient care area is considered a non-patient area, but a health care electrician working in such corridors should be mindful of the effect work might have on patients on the other side of the corridor wall.

Depending on the size and activities within a health care facility, non-patient areas can include business and administrative offices, kitchens, cafeterias, gift shops, utility centers, the electrical shop, and auditoriums. The work of a health care electrician in these areas would be basically the same as that in any commercial building, with the caution noted above.

Laboratories are non-patient areas, except in cases where patients are routinely brought to the laboratory for some kind of treatment. In that situation, the area where the patient is seen would be considered a patient care area, and all requirements for patient care areas would apply. A health care electrician should always contact the laboratory safety officer before doing any work in a laboratory.

A non-patient area of a different nature in hospitals is the central sterilizing area. Here, in addition to electrical hazards, you must deal with the issues of moisture and maintaining sterility. Moisture and humidity reduce skin resistance, and thus add to the conductivity issue. A health care electrician needs to know what procedures and policies are in effect before working in such areas in order not to compromise sterilized items intended for patients.

A major area of health care electrician involvement can be in the utility supply center (USC). Here, utilities come into the facility (or are generated), and then are distributed to necessary portions of the facility. While most of the electrical distribution system wiring within the USC will be similar to a commercial building, some equipment and distribution methods will be very different, enabling the facility to continue to care for patients if normal power is interrupted. (This is opposed to electricity used just to enable occupants to safely leave the building). A health care electrician needs to know: 1) how the essential electrical system functions, including the separation of certain wiring, and 2) the special medical systems in the USC, such as piped medical-surgical gas and vacuum systems, that have to continue functioning in an emergency.

Patient care areas — Working in or near a patient care area necessitates additional precautions because of the presence of patients. The following is a general list of do's and don'ts that should be incorporated into a health care electrician's modus-operandi when working in these areas.

No surprises!
When a health care electrician is requested to enter a patient care area in which patients are present and being treated, he or she needs to notify the person in charge of the area of his or her presence, as well as the type of work to be done. The person could be a nurse, a floor coordinator, etc. This check-in must be done every time.
Use discretion
Health care electricians appear quite different from medical and nursing staff in terms of their apparel. As such, electricians need to be aware that their presence can add more anxiety to patients who may already be nervous about their condition, how they look, their lack of personal privacy, etc. Electricians need to speak in as low a volume as possible, and keep their eyes focused on the work to be done.
Clean your hands
Cleaning hands with some type of anti-bacterial cleanser is an easy way to help keep infection levels down when working in patient care areas.
Dress appropriately
Anesthetizing locations (including operating rooms, corridors, scrub areas, and recovery rooms within that area) have the air within them highly filtered and under a slight positive pressure in order to keep the air cleaner than other portions of the health care facility. This cleanliness level means that people working in the area (surgical and non-surgical persons) need to change out of their ordinary clothes that have been exposed to “dirty” air, and wear clean operating room gowns. Head and facial hair has to be covered. Masks are worn over the nose and mouth to reduce the germ level in the air. Covering of shoes is also required. Health care electricians need to know the procedures required by a facility before entering and working in an anesthetizing location.
Keep the dust down and out
When noise, dust, or moisture is created from work, precautions are necessary to prevent more problems from affecting patients in or near the area. These precautions can take several forms — from a small covering to sealing off an entire room. The appropriate form needs to be determined so the health care electrician can perform his or her work while not compromising patient care in the next room.
Work under pressure
Pressure differentials (positive and negative) from normal atmospheric pressure are necessary to treat certain medical problems. This is either to protect patients from germs outside the patient care area or to keep the rest of the facility safe from the germs inside the patient care area. This includes areas such as anesthetizing locations (as noted above), infectious disease rooms, and hyperbaric chambers. A health care electrician needs to know if a room has controlled pressurization, and what precautions must be observed if work needs to be done in these areas. Precautions can range from caps and gowns to a mask covering nose and mouth, hand gloves, and shoe coverings.
Keep the noise level down
During certain medical procedures, even the tearing of a piece of paper, for example, might cause a surgeon to move or momentarily lose concentration. Although this does not occur often, a health care electrician needs to be cautious that a hammer accidentally dropped on a floor or the sound caused by drilling one story below an operating room might be heard in the operating room. An “oops” by an electrician can indirectly cause an “oops” by a surgeon.

Grounding in the patient care area

To reduce the opportunity for extraneous current to find a pathway through patients, the NFPA Health Care Facilities Committee Project (responsible for NFPA 99, “Standard for Health Care Facilities”) established performance criteria both for the electrical distribution system (from the point of entry in a building to electric panels to receptacles in a patient care vicinity) and for patient care-related electrical appliances (commonly referred to as electro-medical devices).

For the electrical distribution system, the committee determined that the maximum voltage difference between any two conductive points within a “patient care vicinity” shouldn't be more than 20mV in order not to harm most patients. To meet this performance criteria, the National Electrical Code Committee revised NFPA 70 requirements for the installation of wiring to patient care vicinities.

The first change was improving the ground-wiring system itself through better wiring techniques. The second was the introduction of a redundant grounding concept to further increase reliability of the grounding system by adding a redundant ground from receptacles and other points in the patient bed location to electric panels. Although the focus of this effort was the patient bed location, the wiring outside this area was included since it affected the values measured at the patient bed location. A health care electrician needs to study the requirements for grounding as contained in Chapter 4, Sec. 4.3 of NFPA 99 and in Art. 517 of NFPA 70.

Emergency power

Emergency power in a health care facility is needed for two reasons. The first is the same as in any other occupied building: to enable occupants to safely exit the building in an emergency. The second is to enable the health care facility to treat, or house, patients as long as possible without having to end a procedure or relocate patients. This second reason results in the need to provide electric power not only to patient care areas, but also to those areas and functions that support the caring of patients, including laboratories providing analysis of patient blood, in-house pharmacies, sterilizing equipment, the electric portion of medical gas and vacuum systems, patient communication systems, task illumination lighting in patient care areas, computer systems connected directly to computers being used to key in patient data, etc.

Performance criteria for emergency power can be found in Chapter 4 of NFPA 99, with applicability of requirements listed in Chapters 13 to 18. Criteria were developed for: 1) testing of these alternative power sources in order for them to be as reliable as possible, 2) the transfer switches used to switch between normal and essential power, and 3) the protection of wiring related to exiting the building and that related to patient care. A health care electrician needs to know this information in order to understand how this important electrical system will function in an emergency (i.e., when the normal power is interrupted for any reason).

One critical part of this essential electrical system concept is knowing which circuits (and receptacles) will be connected to the emergency power source when the normal power is interrupted. Thus, Chapter 4 in NFPA 99 requires such receptacles to be identified as readily recognizable by staff. This identification should be simple and consistent throughout the facility (for example, using receptacles of a different color than the rest of the facility).

Special equipment

While many pieces of equipment used for the electrical distribution system in health care facilities are the same as that used in commercial office buildings, there are some equipment items that are unique or manufactured to different specifications. This special equipment is required to be installed in health care facilities, as proscribed in NFPA codes or standards, or by enforcing authorities.

Isolated power systems — An isolated power system (IPS) electrically isolates the phase wires coming into a transformer, thereby providing an extra level of protection should certain electrical faults occur in the output wiring or within electrical devices connected to the IPS. It's important to note that grounding is not interrupted in this system; it is continuous throughout, as if there were no isolation-transformer. A line isolation monitor (LIM) is required for IPS, displaying how well this “isolation” is functioning by monitoring current “leaking” into the ground from phase wires and equipment connected to the output circuits of the IPS. The LIM will alarm (visual light, audible beeping) when the isolation drops below a certain value.

This system is useful to provide additional electrical protection against milliampere-level current faults (as opposed to microampere-current) to patients and staff, while still allowing devices plugged into the IPS output circuits to continue functioning.

Chapter 4, Sec. 4.3, in NFPA 99 lists the performance criteria for isolated power systems. Chapter 13 and 14 of NFPA 99 list where such systems are required to be installed.
Hospital-grade receptacles — Some receptacles have a device plugged into them for several months. Other receptacles can have devices plugged and unplugged into them six or seven times a day. The wear and tear on receptacles in patient care areas became a big issue in the 1960s as more electro-medical devices found their way into these areas.

Because ordinary, commercial-grade receptacles were not able to withstand the use and misuse that occurred, a technical committee of the NFPA Health Care Facilities Project proposed some performance requirements for receptacles installed in patient care areas. Electrical testing laboratories (particularly Underwriters Laboratories) developed a manufacturing standard for this group of receptacles, terming them “hospital-grade” receptacles. To differentiate these receptacles from regular, commercial-grade receptacles, a green-dot was applied to the face of the receptacle.

A health care electrician needs to know where hospital-grade receptacles are required within health care facilities. NFPA 70, Article 517, lists these requirements. Note: Hospital-grade receptacles can be installed wherever regular commercial-grade receptacles are installed. However, the reverse is not true.
Nurse-call systems — While health care electricians may not normally become involved with patient equipment, nurse-call systems may be an exception (or at least the wiring system for them). These systems can now allow the control of a TV, turn some lighting in the room on and off, as well as enable a patient to contact or signal a nursing station.

A health care electrician may need to know the operating specifications of these systems (particularly for their wiring). He or she also needs to know whether they are listed for use in oxygen-enriched atmosphere (i.e., air in which the percentage of oxygen is above the normal 19% to 22%). This information will be printed on the hand-control so users know where the control cannot be placed.
GFP coordination — Coordinated ground-fault protection (GFP) is required in health care facilities so that in the event of a fault by a piece of equipment, for example on the 6^th floor, breakers do not trip, interrupting electrical circuits on all the floors in the building. GFPs need to be set so that interruption of power occurs downstream from the point of fault. This sequence is very important when patient care areas are involved.

Although health care electricians are not expected to set the tripping thresholds of GFPs, they should know that GFPs have been set properly — and that no one has tampered with these settings.

Side effects of work

When working on equipment in a health care facility, a health care electrician needs to know the consequences of working on a particular piece of equipment. Simply telling someone that the power will be interrupted for a certain amount of time in an area would be unacceptable if it would affect patient treatment or his or her condition. While some work may not create a problem, careful planning may be required for other tasks in order not to jeopardize patient safety.

Following are examples of work by a health care electrician that could have various side effects on patient care.

De-energizing a circuit — While the U.S. Occupational Safety & Health Administration (OSHA) requires electric power to equipment to be cut before working on it, a health care electrician must be sure the circuits he or she is going to de-energize will not interrupt power to circuits serving patients.
Testing the APS of EES — NFPA 99, Chapter 4, requires the alternate power source (APS) of the essential electrical system (EES) to be tested 12 times per year, using specific test methods as listed in NFPA 110, “Standard for Emergency & Standby Power Systems.” In addition, manufacturers of emergency generator systems have recommendations as to how their emergency power supplies are to be tested.

If they will be testing these systems, health care electricians need to know all the details of the testing procedures. If areas or devices (such as computers) cannot tolerate power interruption for even a half-cycle, alternative connections are to be made so that no power interruption occurs when normal power circuits are de-energized. Health care electricians also need to be aware that some test methods for emergency generators will use actual electrical loads, while others will use some type of resistive load (and thus not disturb the power going to devices). If actual electrical loads are used, a momentary blip in current will occur. It needs to be ascertained if this momentary blip will affect equipment connected to circuits involved.
Testing a UPS — When testing an uninterruptible power supply (UPS), the major concern is how long the test can be run with respect to the rating of the UPS. Some UPS systems will continue to provide power to devices connected to it for 15 minutes; others an hour or more. A health care electrician must know the specifications of the UPS, and what circuits the UPS is connected to before conducting any type of testing on them.
Testing an IPS — NFPA 99 has a section (4.3) in Chapter 4 on the testing of IPSs. Each IPS panel has a push button for testing whether the LIM will alarm if more than 5mA of current begins flowing in the ground wire of the system. Some LIMs have an automatic switch that does this test on a monthly basis; for these LIMs, only a manual, yearly test is required. A health care electrician needs to know how this testing is to be done.

For IPS located in anesthetizing locations, testing cannot be done while surgery is being performed. This presents some interesting challenges for a health care electrician in terms of when testing can be done.
Testing batty-operated emergency lights in operating rooms — Like an IPS, these battery-operated lighting units (which are wired to general area lighting circuits and turn on when power to these circuits is interrupted) have to be tested periodically (as listed in Chapter 13 of NFPA 99). Again, the time to do this testing has to be coordinated with hospital staff.
Testing regular and GFCI receptacles — NFPA 99 has requirements for testing receptacles in patient care areas. Testing such receptacles is required when they are first installed; however, this step is usually completed before an area is occupied. Testing such receptacles when occupied by patients offers the same challenge as noted for the two previous items (e.g., one cannot just remove a device plugged into a receptacle in a patient care area when the schedule for testing occurs). This testing of receptacles applies to both normal and GFCI-protected receptacles.
Creating/controlling dust — Some types of work and products can generate fine particles during installation, repairs, or renovations. These particles can be hazardous to patients with breathing problems. Plus, they can be combustible. If the work being performed by a health care electrician will generate particles that could reach patients, some method of collecting these particles in the work area, or exhausting them outside (if this method is permitted by environmental protection authorities), needs to be used. The method could be as simple as a vacuum cleaner next to the site of the generation of particles, or it could be some plastic barrier and an air filtering system to isolate an entire room.
Role in a disaster — Health care electricians who work for a health care facility when/if some disaster occurs need to know their role with respect to maintaining or repairing the electrical distribution system should it be affected. This is similar to medical and nursing staff who have an ethical obligation to remain with patients as long as possible in a disaster situation. Health care electricians must participate in disaster drills.

Big picture

Health care electricians are still electricians, but the environment in which they work makes it necessary for them to know how their work affects patients who may not be able to take appropriate action in the event that the electrical system is disturbed or interrupted. Electrical work within a health care facility can also affect medical procedures being performed by staff. Considering what's at stake, health care electricians must learn how to work safely and effectively under these unusual conditions.

Klein is the president of Burton Klein Associates in Newton, Mass.

Sidebar: Electricity and Human Physiology

Humans are responsive to electricity applied to the body. Under normal conditions, we can tolerate a certain amount of externally applied current without permanent or fatal consequences. For patients, that level of tolerance is reduced (e.g., patient may be unconscious, restrained, or under anesthesia with surgeons using electrical devices directly touching organs inside the body). Because health care electricians will be working on or with electricity that could travel in unintentional paths and harm patients, they would do well to attend some classes on human physiology to understand how and why electricity can affect patients more acutely than non-patients.

Sidebar: Industry Resources

Following is a short list of handy references for electricians looking to get into the health care market or for veterans wanting to brush up on their skills.