Stretcher won't fit in the elevator: building code sizes, stairs, and tight halls at NEMT pickups

What the building code promises, and where it stops

Only some buildings must have an elevator that takes a stretcher. Section 3002.4 of the 2021 International Building Code says that where elevators are provided in buildings four or more stories above, or four or more stories below, grade plane, at least one must serve every floor for fire department emergency access. That car has to fit an ambulance stretcher 24 by 84 inches, with corners of at least a 5 inch radius, lying flat and open. It is marked with the star of life, at least 3 inches tall, inside on both sides of the hoistway door frame.

The rule leaves three kinds of buildings out:

• Buildings under four stories. A three-story building with an elevator can have a car of any size the other rules allow.
• Buildings with no elevator. The code does not require one. The ADA standards excuse private buildings under three stories, or with less than 3,000 square feet per story, from connecting floors with an accessible route (section 206.2.3). The exemption does not cover the professional office of a health care provider, shopping centers, or transit stations.
• Older buildings. The International Building Code is a model code that takes effect where a state or city adopts it, so a building follows the code in force when it was built, plus local amendments.

The star of life is the quickest test in a tall building, and a tape measure is the test everywhere else.

Elevator car sizes against cot sizes

Accessibility rules set minimum car sizes for wheelchairs, not stretchers. New elevators must match one of the layouts in ADA Table 407.4.1, or another layout with room for a wheelchair to turn around, and existing cars can stay smaller.

Depth here is measured from the back wall to the front return. Compare those numbers with the equipment your crew brings:

• Standard cot. Stryker’s Performance-PRO XT is 80 inches long standard, 64 inches at its shortest, and 23 inches wide.
• Bariatric cot. Stryker’s MX-PRO Bariatric Transport is 80.5 inches long, 62 inches at its shortest, and 29 inches wide.
• Chair cot. Ferno’s PRO 28Z folds into a 47 by 25 inch chair. Ferno markets it for tight hallways, narrow stairs, and elevators without moving the patient off the cot.
• Stair chair. Stryker’s Stair-PRO is 20.5 inches wide and 28 inches deep.

Only the two 80 inch dimensions come close to a full-length cot, and the code’s stretcher test is 4 inches longer than either. An existing 54 inch car will not take a cot at its shortest setting. A chair cot or a stair chair fits in any of them, but only for a rider able to sit up.

Stairs, landings, and doors

When there is no elevator, the stairs decide the plan. Model code minimums differ for houses and for larger buildings:

• Houses (2021 International Residential Code). Stairs at least 36 inches clear above the handrails, but 31.5 inches at handrail height with one handrail, or 27 inches with a handrail on each side. Headroom of at least 6 feet 8 inches. Landings at least 36 inches deep on a straight run. Spiral stairs may be as narrow as 26 inches.
• Apartment and commercial buildings (2021 International Building Code). Stairs at least 44 inches wide, or 36 inches when they serve fewer than 50 people. Landings at least as deep as the stair is wide, capped at 48 inches. Headroom of at least 80 inches.

Two numbers settle most stair questions. A cot at 64 to 80 inches cannot turn flat on a landing 36 to 48 inches deep and about as wide as the stair, so a stair with a turn usually means a stair chair, or a chair cot in its chair position. And a house stair with two handrails may give only 27 inches at hand height, enough for a 20.5 inch stair chair but tight for crew hands on both sides. Stryker’s powered XPEDITION needs stairs at least 24 inches wide and no steeper than 45 degrees, plus a landing at least 3.28 feet long on U-shaped stairs.

Doors inside a home are another squeeze. The residential code requires one egress door with 32 inches of clear width and says other doors need not meet that size, so a bedroom or bathroom door can be narrower than the front door. A 29 inch bariatric cot is the first to get stuck at a narrow bedroom door. Commercial buildings use the same 32 inch minimum for egress doors.

Questions to ask at booking

The booking call is the cheapest place to find a problem building. Add these to trip intake for every stretcher or stair chair trip, and save the answers on the rider’s profile for the next ride:

1. What floor is the rider on, and how many stories does the building have?
2. Is there an elevator, and does it carry the star of life? Has it been working this week?
3. What are the inside depth, width, and door opening of the car? Ask building staff or a family member to measure.
4. With no elevator: how many steps, counting porch and entry steps, how many turns or landings, and how wide is the narrowest point? Are there handrails on both sides?
5. What is the narrowest door between the rider’s bed and the exit?
6. What does the rider weigh, with any oxygen or equipment that rides along?
7. Can the rider stay seated upright on the stairs or in the elevator, and for how long?
8. Where can the van stop, and how far is it from that door to the entrance? The curb side of that question is in where NEMT vans can park at hospitals.

Matching the building to the crew and equipment

The answers point to one of five plans:

• Stretcher elevator or a car at least 84 inches deep. Bring the standard cot and two or more crew members.
• Small elevator, rider can sit. Use a chair cot in its chair position for the elevator, or a stair chair to the lobby and the cot from there.
• Straight stairs going down, rider can sit. A stair chair. Stryker’s Stair-PRO tread system brings a rider down stairs without lifting, and its 500 pound limit includes the patient plus any equipment and accessories.
• Stairs going up, or a heavy rider. A manual chair has to be carried up, so send a second crew member, or use a powered chair such as the XPEDITION, which climbs and descends. Weigh the rider and the equipment against the 500 pound limit.
• Rider cannot sit at all. A stair chair and a chair cot are both out. The move needs a flat carrying device, for example a scoop stretcher, plus enough hands to carry it on the stairs.

State rules already expect this work. In Virginia the provider owes the rider whatever transfer device the stairs call for, from a stair chair to a scoop or Reeves stretcher, and New York’s crews must carry the stretcher past steps when a building lacks both an elevator and a ramp. Stretcher van equipment lists the gear, and the stair chair entry covers when crews reach for one.

When an ambulance is the right call

Stairs and small elevators do not make a trip an ambulance trip by themselves. The rider’s condition does. A rider who needs watching or treatment during the ride belongs with an ambulance crew, as NEMT or ambulance explains.

Medicare’s coverage rule for ambulance trips, 42 CFR 410.40, gives a useful test for the riders in between. Its bed-confined test has three parts, all required: no getting out of bed without assistance, no walking, and no sitting, whether in a wheelchair or any other chair. Medicare does not treat that as the whole answer; it weighs bed confinement with the rest of the person’s condition. Someone who meets all three parts cannot use a stair chair or a chair cot. If that rider also lives up a turning staircase with no stretcher elevator, call the payer before the trip and ask whether it should go to an ambulance service.

Sending the right crew in HealthRide

HealthRide matches wheelchair, stretcher, oxygen, and stair-chair requirements on every assignment. Mark the stair chair on the trip when you book it, and it counts when the trip is assigned, the same way a stretcher does. Vehicle capabilities are set up in fleet.