Emergency Power and Elective Surgery

Chante Buntin, MD; Jeffrey Feldman, MD, MSE; Charles E. Cowles, Jr., MD, MBA, FASA; Jan Ehrenwerth, MD

Dear RAPID Response:

I read your safety guidelines often for answers, but I could not find one that addresses the question of what types of procedures should be done when only emergency power is available. Specifically, is there any information about the advisability of performing an “elective” surgery during a known black-out and using a back-up generator?

I am aware of a surgeon who is planning elective surgery during power outages related to wildfires and relying solely on back-up power sources for the day.

The surgeon wants some sort of published guidelines stating it is a bad idea to do elective surgery on backup power. Do you know of any?

Thank you for any helpful information you can provide.



Chante Buntin, MD
Diplomat of the American Board of Anesthesiology
Board Certified in Anesthesia, Pain Medicine, Addiction (tbc), Palliative Care and Hospice

The author has no conflicts of interest.



Dear Dr. Buntin,

We are not aware of any specific guidelines indicating that doing elective procedures under conditions of emergency power is a “bad” idea. That said, emergency power systems are limited in capability when compared with the power available under normal conditions and should be used to prioritize the needs for urgent and emergent care. The limitations imposed by emergency power will vary from institution to institution. So, your local capabilities become important in determining what you can or cannot do safely. In general, when power is limited, using the power for non-essential services will have an impact on the power available to provide urgent or emergent care.

The National Fire Protection Association (NFPA) authors standards and codes for power requirements in health care facilities which are followed in the U.S. by the Center for Medicare & Medicaid Service and the Joint Commission.1 All health care facilities are required to have 2 independent sources of power with one being on site. Usually these sources are the utility company and a generator. As for the generator capabilities, the requirements for electrical capacity and available fuel supplies to support run times are addressed by NFPA codes but ultimately determined by your local authorities.

There is an established hierarchy for prioritizing power distribution, which is determined by the NFPA’s National Electrical Code (NEC).1 Power to the life safety branch, is first and includes power to exit signs, door unlocking mechanisms, alarms, and emergency hallway lighting. Next is the critical branch, which is for the well-being of patients and includes clinical equipment plugged into “red outlets” present in the operating rooms, ICU, nursery, nurse call systems, and pharmacy storage. Last is the equipment branch, which is everything else.

Understanding the capabilities of on-site generators is essential to making an informed decision about what type of activities can be supported when the utility power is not available. All generators have a rated capacity in kilowatts. One generator may be able to provide emergency power to the hospital but will be limited by its maximum capacity. Two or more generators is desirable as it provides redundancy in the event that one of the generators fail. Generators also will be limited by the available fuel supply.

The amount of time the generators will be able to supply power will be determined by the available fuel and the power requirements that will need to be satisfied. While NFPA does not prescribe the minimum run time required, language in the NFPA guidelines provides direction for hospitals to determine their needs. NFPA 110 is the standard for emergency and standby power for different types of facilities. Hospitals are considered Class X facilities and are provided the flexibility to determine minimum needed run times based upon their needs and local codes. NFPA 99 is the standard governing fire and life safety requirements for health care facilities. NFPA 99 includes the following statement to guide the minimum run time for generators: “The hospital should determine the appropriate run time for the emergency electrical supply and size the fuel tanks accordingly.Careful consideration should be given to the potential types of outages anticipated and the availability of fuel. It should be noted that in some situations it might be permissible to size the fuel system to accommodate less than 48 hours of fuel. If life safety systems will need emergency power, other codes and standards might specify minimum durations of required operation.1” Interviews with experts from NFPA indicate that 48 hours of generator capacity is a good target for run times, but in some locations (e.g., earthquake zones) 96 hours is desirable.

While generators are a mature technology, unfortunately, they are well known to fail. For example, during Hurricane Sandy in 2012, a number of hospitals encountered problems with their generators when utility power stopped, including complete power failure in a major academic center.2

We would suggest that you engage the local facilities management to understand the capabilities of the emergency electrical supply. To make an informed decision, you will need to know the maximum power of the generators relative to the anticipated power needs, whether or not there is more than one generator in case of failure, how long the generators will run with the available fuel supply, and the anticipated needs for power to care for existing patients and support any urgent and emergent care needs.


Jeffrey Feldman, MD, MSE, is professor of clinical anesthesiology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, and chair of the APSF Committee on Technology.

Charles E. Cowles, Jr., MD, MBA, FASA, was associate professor and chief safety officer at the University of Texas MD Anderson Cancer Center, Houston, TX.

Jan Ehrenwerth, MD, is professor emeritus at Yale University School of Medicine, New Haven, CT.

The authors have no conflicts of interest.


  1. Overview of NFPA codes and standards that apply to emergency power systems in healthcare facilities. https://nfpa.org/Codes-and-Standards/Resources/Standards-in-action/NFPA-resources-for-CMS-requirements-on-NFPA-99-and-NFPA-101/Action-for-emergency-power-in-Florida Accessed December 21, 2020.
  2. Lessons learned from Hurricane Sandy and recommendations for improved healthcare and public health response and recovery for future catastrophic events. American College of Emergency Physicians, Dec 22, 2015. https://www.acep.org/globalassets/uploads/uploaded-files/acep/by-medical-focus/disaster/lessons-learned-from-hurricane-sandy-webpage.pdf Accessed December 21, 2020.

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.

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