More on Corridor Doors

Q: If the corridor doors are only required to resist fire for 20 minutes and someone plasters signage all over them or loads them up with coat racks adding to the fuel load, then who decides if they would still resist fire conditions for 20 minutes?

A: The doors are not required to resist fire for 20 minutes. They are required to be 1¾ inch thick, solid-bonded, wood core, or of such construction that resist fire for not less than 20 minutes. That is not the same as saying they are required to resist fire for 20 minutes.  Therefore, nobody has to decide if they still resist fire for 20 minutes, because the construction of the door was determined acceptable before any items were added to the door. This may sound like a technical loop-hole, but the point I’m trying to make is there should not be a reason for anyone to determine if a corridor door resists fire for 20 minutes. NFPA has indicated that a 1¾ inch solid-bonded, wood-core door is of such construction to resist fire for up to 20 minutes (see section 8.2.3.2.3.2 of the 2000 LSC).

Corridor Doors

Q: I have read that corridor doors to patient rooms are not required to have closers. If they do have closers, I was told they can have the type that have hold open closer arms, then someone must physically close them.  Hospitals are defend in place facilities so why rely on people to accomplish this?

A: Corridor doors to patient rooms are not required to have closers, according to 19.3.6.3.2 of the 2000 LSC. The concept of having corridor doors to patient rooms without closers allows staff to visibly see into the room to detect any fire or smoke condition. If the door had a closer, then the Annex section recommends the room be protected with a smoke detector. The basic premise of a healthcare occupancy is there is adequate staff on hand to make these observations.

Corridor Width

Q: Can you give me the NFPA Life Safety Code (2000 edition) reference showing 8 foot required width in egress corridors in an existing healthcare occupancy?

A: There is no direct LSC reference that requires 8 feet wide corridors in existing hospitals. But; it’s an interpretation. Section 19.2.3.3 of the 2000 Life Safety Code says corridors have to be at least 4 feet wide in existing healthcare occupancies. Section 4.6.7 says when you make alterations, you must meet new construction requirements. Section 18.2.3.3 requires 8 feet wide corridors in new construction healthcare occupancies. So, let’s say you have 7 foot wide corridors in an existing hospital. That’s legal. But the minute you make an alteration (including storing something non-combustible in the corridor) now it must meet the requirements for new construction, which is 8 feet. So, the correct way of stating corridor width in existing healthcare occupancies is the corridor must be free and clear up to 8 feet wide. If the corridor is 7 feet wide: That’s okay as long as the width is free and clear.

Handrails in Corridors

Q: I am working on an aesthetic corridor remodel for a hospital. Can you please tell me if there are specific requirements as to handrail locations (i.e- one side of the wall vs. both sides, at what locations, for what amount of distance, etc.)?

A: In regards to healthcare occupancies, and specifically hospitals, there is no Life Safety Code requirement for handrails in an exit access corridor. There are requirements for stairs, exit enclosures, ramps and exit passageways to have handrails, but the LSC does not have any requirements for corridors. However, there are other codes and standards to consider. The Facility Guidelines Institute requires hospitals to comply with ADA requirements in regards to handrails in corridor, unless the functional program narrative specifically decides against them. What this means, if the hospital has a written program that describes the use and activities that the corridor serves is not consistent with handrails, then it is permissible not to install them. An example of this may be a Psychiatric unit where a handrail could possibly be removed and used as a weapon. In essence, the hospital gets to decide if there will be handrails, but the reason needs to be plausible and written down in a program narrative. Also, compliance with ADA requirements is required whenever new construction or renovation of an existing area is conducted. I do not believe just installing new wallpaper qualifies as renovation, so compliance with ADA would not be required. I strongly recommend that you contact the local and state authorities to determine if they have regulations that would require handrails.

A Follow-Up to “Comments on Corridor Clutter”

The following comment is a result of an article that I ran last August on corridor clutter (search: Comments on Corridor Clutter), which quoted Randy Snelling, the Chief Physical Environment Officer for DNV.GL Healthcare, Inc. This comment is from a representative from a state agency that performs surveys on behalf of CMS.

First, I totally agree with both Randy and you. Both in principle and standard we should be  more up to date and facilities should know what the standard is and how to  follow it. Oddly, I spend more time assisting facilities on this issue even when I cite it. I tend to smile when they announce I have arrived and wonder “Were you in compliance yesterday?”

As a surveyor doing checks on all occupancies, I have found none ever seem to not have some issue with space and where to place those items needed for patient/resident care. Having worked in a healthcare facility, I can also fully relate that focus being first and foremost.

That being said, the standard is there for a reason and has been for some time.  Even though my initial peek into 2012 finds some increasing awareness of how clutter is viewed, I still believe that we have a wide arrangement of options if, as both you and Randy point out, senior management buys into it and
supports either their Safety Manager or Maintenance staff.

Inevitably, these are the ones who take it very personally when I cite a facility for a blocked or obstructed corridor. Administrators, Chief Nursing Officers on down need to understand the reasoning behind the code and what steps it takes to stay in compliance. I feel a majority of the time the facility management thinks “Oh we clear everything when the drills happen”. Now imagine those corridors filled top to bottom with smoke. The scenario will change considerably. I hope all who read your article and Randy’s comments take it to heart.

I think this representative for a state agency makes a very good point: The healthcare industry needs better education on the need to keep the corridors clear from clutter. I suspect we have become insensitive to this issue because the frequency of fires in hospitals has dropped dramatically since the mid-1980’s, when smoking was restricted in hospitals.

But fires still occur in healthcare settings as documented in either this blog or in the HCPro’s Healthcare Life Safety Compliance newsletter. And it is the belief of Randy and I (and this representative from a state agency) that corridor clutter still needs to be taken seriously.

In my opinion, it did not help that the NFPA Life Safety Code technical committee decided to allow certain unattended items in corridors of 8 feet as described in the 2012 edition. It also didn’t help that CMS decided to endorse this section of the 2012 edition last year as a categorical waiver. The decision on the technical committee to do this was not unanimous, as a representative from a state agency who surveys hospitals (not the same individual quoted above) enthusiastically opposed the decision. Since he had first-hand observation on how hospitals abuse codes and standards, he did not want to allow them to store items in the corridor.

I suspect corridor clutter will remain a problem until senior leadership decides to take an active role in resolving it.

Comments on Corridor Clutter

Randy Snelling, the Chief Physical Environment Officer, for DNV-GL Healthcare Inc. spoke at the recent ASHE annual conference in Chicago, and I thought his views on corridor clutter were worth repeating here…

“I read in the ASHE magazine recently an article written by a surveyor who listed the top 5 findings he saw during a survey”, says Snelling. “The first thing he identified was corridor clutter. I threw the magazine across the room. I thought, ‘Man, where are we? This is 2014 and we’re still talking about corridor clutter? Really? Come on!’ Why is corridor clutter still happening in hospitals? Because the senior leadership is not stepping in. The facility manager does not have the clout with those clinicians up on the floors where the corridor clutter occurs. But who does? Senior leadership. And if you’ve got corridor clutter problems, it’s not a life safety problem, it’s a ‘C’ suite problem. And our hospitals know it. I don’t think we’ve had a corridor clutter finding in over a year. Now, what happens? Well, we come in and the hospital makes an announcement overhead welcoming the DNV survey team, and everything gets moved out of the corridor. But that happens with everybody else too, with HFAP and TJC and CMS. So why are we seeing this? I think it is because since we are in the hospital every year our hospitals do not have as much to move out of the corridors as other accredited hospitals. This ends up being a problem with Leadership rather than a problem with the facility manager.”

I consider Randy to be a friend and we talk frequently about accreditation issues. I think his view on corridor clutter on the nursing units is spot on, in that senior leadership needs to back the facility manager (or safety officer) on Life Safety Code issues that are out of their capability. Having been a Safety Officer at a hospital for years I can relate to this problem. I rarely felt the support from the ‘C’ suite and felt I had to struggle with certain basic life safety requirements (such as corridor clutter) on my own.

I did eventually take a different approach by spending time on the nursing units observing the nurses day-to-day operations. This made me realize their needs better and they eventually saw me as one who wanted to help, rather than the enemy who was always telling them to move their equipment out of the corridors. I was able to apportion capital funds to build alcoves in certain locations, and they in turn kept the corridor free from clutter.

But most hospitals probably still struggle with corridor clutter issues and without the senior leadership stepping in and backing the facility manager by insisting items be stored in alcoves and storage rooms, this problem will not go away. I predict it will get worse when the 2012 Life Safety Code is finally adopted, since the new LSC allows certain unattended items to be placed in corridors that are at least 8 feet wide. That will create a struggle for everyone as most staff will not understand what pieces are permitted and what pieces are not permitted.

Corridor Doors vs. Cross-Corridor Doors

Cross Corridor door web 2I have seen many facility managers (and surveyors for that matter) incorrectly refer to a door as a ‘corridor door’. It appears that they believe as long as the door is accessible from the corridor, then it must be a corridor door. That is not always the case, but it is understandable as corridor doors may be confusing.

A corridor door is a door that separates a room from a corridor, and they are usually mounted parallel to the corridor. Corridor doors are often found on entrances to patient rooms, utility rooms, offices, dining rooms, and the like. Corridor doors are often (but not always) a single-leaf door.

A cross-corridor door is a door that separates a corridor from another corridor, and they usually are mounted perpendicular to the corridor. They are typically used as privacy doors, smoke compartment barrier doors, and fire-rated doors in a horizontal exit or an occupancy separation. Cross corridor doors are usually (but not always) double-leaf doors, and if considered new construction, must be double egress, meaning one leaf swings in one direction and the other leaf swings in the opposite direction.

In reviewing accreditation organization survey reports, I have read where surveyors often refer to ‘corridor doors’ when they really mean something else. According to the Life Safety Code, a corridor door is not required to have a self-closing device (closer), unless it also doubles as a door to a hazardous room, a smoke compartment barrier door, or a fire-rated door. Also, a corridor door must latch, while a smoke compartment barrier door does not have to latch. If a door serves more than one purpose, then the most restrictive requirements must apply.

When referring to the many different types of doors that are accessible from the corridors, always refer to them by their most restrictive requirements:

  • Fire-rated doors to hazardous rooms, exit enclosures, horizontal exits, and occupancy separations
  • Smoke compartment barrier doors
  • Corridor doors to hazardous rooms, or non-hazardous rooms
  • Privacy doors

A privacy door that is a cross-corridor door is not required to latch, or be self-closing; but a privacy door that is a corridor door would be required to latch, since the requirements for a corridor door are more restrictive.

Smoke Compartment Barrier Door Gaps

Smoke compartment barrier doorsI want to clarify a confusing point in the seven-year old CMS S&C memo 07-18 issued April 20, 2007. This is a memo which CMS wanted to explain that corridor doors that are not fire-rated or used in a smoke compartment barrier are permitted to have gap clearances up to ½-inch in smoke compartments that are protected with sprinklers. In this memo they have conflicting points; the subject line of the memo stated: “Permitted Gaps in Corridor Doors and Doors in Smoke Barriers”, but in the content of the memo they say “This information does not apply to doors in smoke barriers, which have other requirements.”

Click on this link to access this CMS memo:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/CMS1198675.html?DLPage=1&DLFilter=07-18&DLSort=3&DLSortDir=ascending

To be clear, the maximum gap for the proper clearance of smoke compartment barrier doors is 1/8 inch; not ½ inch, and it is not dependent on whether or not the smoke compartment is sprinklered. Sections 18/19.3.7.6 of the 2000 LSC references section 8.3.4 of the same code and the Annex section of 8.2.4.1 says the maximum gap for smoke compartment barrier door clearances is 1/8 inch.

The CMS memo addressed corridor doors that are not fire-rated or located in a smoke compartment barrier. Corridor doors are those doors which separate a room or an area from the corridor. Can a corridor door also be a fire-rated door or a door in a smoke compartment barrier? Yes, certainly; and in those situations the more restrictive requirements must apply.

The bottom line: Doors in smoke compartment barriers must not have gap clearances that exceed 1/8 inch per the 2000 LSC. The CMS S&C memo 07-18 only applies to non-fire-rated corridor doors that are not located in a smoke compartment barrier.

Privacy Curtains or Screens?

Q: The health care facility where I work needs additional privacy on the nursing floor from the rest of the building.  I would like to know if we could mount a ceiling track across the beginning of the nursing hallway, with a lightweight privacy curtain that can be drawn open or closed as needed; or place two decorative lightweight free-standing folding screens placed at the entrance to the nursing hallway.?

A: Assuming the nursing hallway that you refer to is an exit access corridor; then no, neither option that you suggest would comply with the LSC. Section 19.2.3.3 of the 2000 LSC edition requires the corridor to be arranged to avoid any obstructions for the convenient removal of non-ambulatory patients. That means nothing may be placed in the corridor that could obstruct access, such as the screen. A curtain hanging down from the ceiling would not be permitted according to section 7.5.2.2, which could conceal the path to the exit. However, permanently installed side-hinged swinging privacy doors would be permitted and are often used in situations like the one that you described. The new barrier for the doors would not have to extend to the deck above and would be permitted to terminate at the ceiling. The doors and frame would not be required to be fire rated, and would not have to have positive latching hardware. Any changes to the facility should be reviewed by your state and local authorities.

Alcoves and Areas Open to the Corridor

Alcove Web 2When does a wide spot in the corridor have to meet the requirements for areas open to the corridor? This question was raised to me in regards to a clean linen cart parked in an alcove of the corridor. Does it have to comply with the section on corridor width or the section on areas open to the corridor? This is just one more example of an issue that is not clearly defined in the Life Safety Code and as best as I can tell, the answer lies with the authority making the interpretation of the code.

First we need to understand the two issues. According to section 18.2.3.3 of the 2000 edition of the LSC, corridors in areas that are intended for the housing, treatment or use of inpatients in new construction healthcare occupancies are required to be no less than 8 feet wide in clear and unobstructed width. In areas where inpatients are not expected to use the corridors, the clear and unobstructed width is required to be 44 inches. Corridors wider than the required width are permitted to have alcoves that contain non-combustibles as long as the alcove area does not exceed 50 square feet, and does not encroach on the required width of the corridor. If it exceeds more than 50 square feet, then the area could be classified as a hazardous area if it contained combustibles, and clean linen would most certainly be classified as combustible. So, the alcoves need to be no more than 50 square feet, if they are going to contain clean linen carts.

According to section 18.3.6.1, areas open to the corridor must comply with a variety of requirements, which includes smoke detectors. But if the alcove is considered a wide spot in the corridor, then it would not have to comply with section 18.3.6.1 and have smoke detectors. So, the question remains: When is an alcove just a wide spot in the corridor and when does it have to meet the requirements for 18.3.6.1 and have smoke detectors?  And if we are asking the same question for existing conditions, it gets a bit more complicated as sprinklers may or may not be required.

Anyway… When the Life Safety Code is not clear, then the answer is up to the authority having jurisdiction to make an interpretation and rule on the issue. The LSC actually says that (in so many words) in section 4.6.1.1. So, if I were the AHJ, I would say an alcove is just a wide spot in the corridor and does not have to meet the requirements for areas open to the corridor in sections 18/19.3.6.1. But, I’m not the AHJ, and they never ask me what I think anyway.