• To demonstrate to hospitals the need for
isolated systems
• To guide the engineer in the application of
hospital ungrounded systems
• To describe in detail the Square D equipment
used to design effective and economical
isolated ungrounded systems
Square D has been building isolating transformers
for hospital use since the first equipment
standards appeared in 1944. We have built an
enviable reputation for reliability, low sound levels ,
and minimum inherent leakage.
Proof of the engineered superiority of Square D
products is found throughout the country in
numerous installations, many dating to the
earliest applications of isolating transformers.
This bulletin is not intended as a “do it yourself”
manual for installation of hospital isolated
systems. The information contained here
regarding codes and standards is current as of
this writing. However, these codes and standards
are continually changing and are also subject to
local changes and interpretations.
Any hospital considering design changes to
electrical systems in critical care patient areas
should obtain the services of an electrical
consulting engineer. The technical complexities of
today’s hospitals dictate that all involved parties
have a thorough understanding of the hospital’s
objectives. This is the only way to avoid
purchasing unnecessary equipment.
Time spent planning the changes will result in
large dividends, provided the following parties
are involved:
• Consulting engineer
• Hospital administrator
• Hospital engineer
• Chief of surgery
• Chief of anesthesiology
• Cardiologist
• Manufacturer’s representative
HISTORY
During the 1920s and ’30s, the number of fires
and explosions in operating rooms grew at an
alarming rate. Authorities determined that the
major causes of these accidents fell into two
categories:
• Man-made electricity
• Static electricity (75% of recorded incidents)
In 1939, experts began studying these conditions
in an attempt to produce a safety standard. The
advent of W orld W ar II dela y ed the study’ s results
until 1944. At that time, the National Fire
Protection Agency (NFPA) published “Safe
Practices in Hospital Operating Rooms.”
The early standards were not generally adopted
in new hospital construction until 1947. It soon
became apparent that these initial standards fell
short of providing the necessary guidelines for
construction of rooms in which combustible
agents would be used.
NFPA appointed a committee to revise the 1944
standards. In 1949, this committee published a
new standard, NFPA No. 56, the basis for our
current standards.
The National Electrical Code (NEC) of 1959 firmly
established the need for ungrounded isolated
distribution systems in areas where combustible
gases are used.
In the same year, the NEC incorporated the NFPA
standards into the code. The NFPA No. 56A–
Standard for the Use of Inhalation Anesthetics,
received major revisions in 1970, 1971, 1973,
and 1978.
In 1982, NFPA No. 56A was incorporated into a
new standard, NFPA No. 99—Health Care
Facilities. The new document includes the text of
several other documents, such as:
• NFPA-3M• 56HM
• 56K• 56B
• 76A• 56C
• 76B• 56D
• 76• 56G
The material originally covered by NFPA 56A
is now located in Chapter 3 of NFPA No. 99.
NFPA No. 99 was updated in 1984, 1987, 1990,
1993 and 1996.
The increased use of electronic diagnostic and
treatment equipment, and the corresponding
increase in electrical hazards, has resulted in the
use of isolated ungrounded systems in new areas
of the hospital since 1971. These new hazards
were first recognized in NFPA bulletin No. 76BM,
published in 1971. Isolating systems are now
commonly used for protection against electrical
shock in many areas, among them:
• Intensive care units (ICUs)
• Coronary care units (CCUs)
• Emergency departments
• Special procedure rooms
• Cardiovascular laboratories
• Dialysis units
• Various wet locations
ELECTRICAL HAZARDS IN HOSPITALS
The major contributors to hospital electrical
accidents are faulty equipment and wiring.
Electrical accidents fall into three categories:
• Fires
• Burns
• Shock
This section covers the subject of electrical shock.
Electrical shock is produced by current, not
voltage. It is not the amount of v oltage a person is
exposed to, but rather the amount of current
transmitted through the person’s body, that
determines the intensity of a shock. The human
body acts as a large resistor to current flow. The
average adult exhibits a resistance between
100,000 ohms (Ω) and 1,000,000 Ω, measured
hand to hand. The resistance depends on the
body mass and moisture content.
The threshold of perception for an average adult
is 1 milliampere (mA). This amount of current
will produce a slight tingling feeling through
the fingertips.
Between 10 and 20 mA, the person experiences
muscle contractions and finds it more difficult to
release his or her hand from an electrode.
The hazardous levels of current f or many patients
are amazingly smaller. The most susceptible
patient is the one exposed to externalized
conductors, diagnostic catheters, or other electric
contact to or near the heart.
Surgical techniques bypass the patient’s body
resistance and expose the patient to electrical
current from surrounding equipment. The highest
risk is to patients undergoing surgery within the
thoracic cavity. Increased use of such equipment
as heart monitors, dye injectors, and cardiac
catheters increases the threat of electrocution
when used within the circulatory system.
Other factors contributing to electrical
susceptibility are patients with hypokalemia,
acidosis, elevated catecholamine levels,
hypoxemia, and the presence of digitalis. Adult
patients with cardiac arrhythmias can be
electrocuted through the misuse of pacemakers
connected directly to the myocardium.
Infants are more susceptible to electric shock
because of their smaller mass, and thus lower
body resistance. Much has been written about
current levels considered lethal for catheterized
and surgical patients. Considerable controversy
exists about the actual danger level for a patient
who has a direct electrical connection to his or her
heart. The minimum claimed hazard level seems
to be 10 microamperes (µA) with a maximum level
given at 180 µA. Whatever the correct level,
between 10 and 180 µA, it is still only a fraction of
the level that is hazardous to medical attendants
serving the patient.
It is believed that approximately 1,000 Ω of
resistance lies between the patient’s heart and
external body parts.
All of this information leads us to the conclusion
that the patient environment is a prime target for
electrical accidents. Nowhere else can one find
these elements: lowered body resistance, more
electrical equipment, and conductors such as
blood, urine, saline, and water. The combination
of these elements presents a challenge to
increase electrical safety.
An externally applied current of 50 mA causes
pain, possibly fainting, and exhaustion.
An increase to 100 mA will cause ventricular
fibrillation.
Electric equipment operating in the patient vicinity ,
even though operating perfectly, may still be
hazardous to the patient. This is because every
piece of electrical equipment produces a leakage
current. The leakage consists of any current,
including capacitively coupled current, not
intended to be applied to a patient, but which may
pass from exposed metal parts of an appliance to
ground or to other accessible parts of an
appliance.
Normally, this current is shunted around the
patient via the ground conductor in the power
cord. However, as this current increases, it can
become a hazard to the patient.
Isolated systems are now commonly used to
protect against electrical shock in many areas,
among them:
• Intensive care units (ICUs)
• Coronary care units (CCUs)
• Emergency departments
• Special procedure rooms
• Cardiovascular laboratories
• Dialysis units
• Various wet locations
Without proper use of grounding, leakage
currents could reach values of 1,000 µA before
the problem is perceived. On the other hand, a
leakage current of 10 to 180 µA can injure the
patient. Ventricular fibrillation can occur from
exposure to this leakage current.
Figure 1 illustrates the origin and path of leakage
current.
Failure to use the grounding conductor in power
cords causes a dangerous electrical hazard. This
commonly results from using two-prong plugs and
receptacles, improper use of adapters, use of twowire extension cords, and the use of damaged
electrical cords or plugs. Figure 2 illustrates these
hazards.
Answers
There are no perfect electrical systems or infallible
equipment to eliminate hospital electrical
accidents. However, careful planning on the part
of the consulting engineer, architect, contractor,
and hospital personnel can reduce electrical
hazards to nearly zero. Hospital electrical
equipment receives much physical abuse;
therefore, it must be properly maintained to
provide electrical safety for patients and staff.
Procedures for electrical safety should include the
following:
• Check all wall power receptacles and their
polarities regularly.
• Routinely verify that conductive surfaces are
grounded in all patient areas.
• Request that patient electrical devices such as
toothbrushes and shavers be battery powered.
• Use completely sealed and insulated remote
controls for use in patient beds.
• Use bedrails made of plastic or covered in
insulating material.
5
General Information and Application
Codes and Standards
CODES AND STANDARDS
It would not be practical to attempt to reproduce
the codes and standards that affect the
application of isolated distribution systems in
hospitals. As was previously mentioned, codes
are continually refined and updated, with frequent
amendments between major publications. All
hospitals should have copies of the current
standards for reference; the design engineer
must
have this information available. Obtain
copies of all standards referenced in this bulletin
from the National Fire Protection Association,
Batterymarch Park, Quincy, MA 02269.
This chapter briefly covers the sections of codes
and standards that apply to hospital isolated
ungrounded distribution systems. This chapter
only covers a few of the important points within
these standards. A thorough study of applicable
codes and standards is required to effectively
design a project.
NFPA No. 99
History
Published by the NFPA, this code is included as a
reference in the NEC Article 517.
NFPA No. 99 addresses fire, explosion, and
electrical safety in hospitals. It consolidates 12
individual NFPA documents or standards into
one document.
Many hospitals and consulting engineers are
unaware of this document and its requirements.
Square D recommends that all consulting
engineers who design hospitals have the
hardcover “handbook” version of this document
available.
Anesthetizing Location Classifications
The first type of location is that which is flammable
because explosive anesthesia is used. This
location must be designed to comply with NEC
Article 501.
There are many other requirements for the
flammable anesthetizing locations; these
requirements are discussed in Chapter 12 of
NFPA No. 99. Explosive anesthesia is now
virtually non-existent in the United States.
Therefore, this handbook does not cover the
flammable location in any detail.
Non-flammable anesthetizing location
requirements are also covered in Chapter 12 of
NFPA No. 99. A permanent sign must be
displayed at the entrance to all flammable
locations. It must state that only non-flammable
anesthetics can be used in the room.
Non-flammable anesthetizing locations can be
further divided into locations that are subject to
becoming wet and those that are not. A wet
location requires special protection against
electrical shock. The allowable protection is
as follows:
• Ground-fault circuit interrupter if first-fault
conditions are to be allowed to interrupt power
• Isolated power system if first-fault conditions
are not to be allowed to interrupt power
The governing body of the hospital will make the
determination of a “wet location,” using the
following definition:
A patient care area that is normally subject to
wet conditions while patients are present. This
includes standing fluids on the floor or
drenching of the work area, either of which
condition is intimate to the patient or staff.
Routine housekeeping procedures and
incidental spillage of liquids do not define a
wet location.
NFP A No . 99 defines the items in an anesthetizing
location, which must be powered from the isolated
ungrounded system. Because this section is
subject to individual interpretation by local Code
authorities, work closely with these authorities
before selecting the equipment to be powered
from standard grounded systems. This is
especially important when ordering permanently
installed equipment, such as X-ray apparatus.
NFPA No. 99 and the NEC Article 517 allow the
grounded circuit providing power to an isolated
system to enter the non-hazardous area of an
anesthetizing location. However, ungrounded
wiring and grounded service wiring cannot occupy
the same conduit or raceway.
The primary and secondary of the isolation
transformer cannot exceed 600 volts (V) in any
isolation system that supplies power to an
anesthetizing area or other critical care patient
area. The secondary circuit conductors must be
provided with an approved overcurrent protective
device in both conductors of each branch circuit.