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One Misunderstood Guideline in Sterile Processing - The 18-inch Supply Storage Ceiling Limit

Updated: 19 hours ago

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Thought of the Week

One of the most often asked questions in the sterile processing department is, "What are the requirements for storing supplies"? It is a fairly straightforward question. You would think that the answer is fairly straightforward, but it is not. You can research numerous resources to get the information you need for the storage requirements. For example, ANSI/AAMI ST79 2017, NFPA 13, ANSI/ASHRAE/ASHE Standard 170-2017, and the FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities all provide information on the design and functionality of the storage areas. The one design caveat that can trump all others is when the construction occurred for the facility and, importantly, the time frame of the last renovation of the area for which your supplies are stored. Guidelines are often updated, but you need to reference the documents that were current for the construction period of your facility in most cases. The one guideline that seems more often than not to be confused is the storage of supplies for fire protection, better known as the "18" rule."

The 18-inch Supply Storage Guideline In Sterile Processing

Sterile processing departments (SPD) across the country have come up with many creative ways to comply with the 18-inch supply storage guideline (otherwise known as NFPA 13 The NFPA 13 2022 guideline states: *The clearance between the deflector and the top of storage shall be 18 in. (450 mm) or greater. Some SPD departments have painted red lines on the walls indicating the 18" threshold so as not to go above it. Others have set the top shelves on their storage units to the height of 18" from the sprinkler head, indicating any item on the top shelf violates the code. These attempts at compliance are easily understood and can easily be evaluated by the staff. However, if you noticed, there is an (*) in the guideline.

The NFPA 13 2022 (*)

The NFPA 13 2022 guideline states: The 18 in. (450 mm) dimension shall not limit the height of shelving on a wall or shelving against a wall in accordance with The NFPA 13 guideline guideline states: Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, shall be permitted to extend above the level of a plane located 18 in. (450 mm) below ceiling sprinkler deflectors along with guideline stating: Shelving, and any storage thereon, directly below the sprinklers shall not extend above a plane located 18 in. (450 mm) below the ceiling sprinkler deflectors.

Do your homework to ensure there are no sprinkler heads directly above the storage units arranged along the wall. And, if not, you have gained additional storage space that is most likely going unused. Do not make the mistake of adjusting other storage units, as all else applies to the 18-inch rule. The theory is that sprinkler heads can not distribute water effectively if something is blocking it, but in the case of a wall, the wall is already blocking the water. So no harm, no foul.

Not too long ago, I was working with a CMS consultant preparing for a go-live in a new Sterile Processing Department. Immediately upon entering the supply storage area, the consultant pointed out that the supplies in the storage area were out of code. I addressed the guideline with the consultant utilizing the NFPA guidelines while also conferring with a CMS inspection firm consultant. The response I got from the CMS consultant was " we really don't like people knowing this." The consultant then approved the storage area based on the guidelines. Be knowledgeable of your guidelines and go forth and conquer!

At Evolved Sterile Processing, our consultants have a greater focus on sterile processing. With our decades of experience, we will help you develop better processes and educational resources for your staff.

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