Evacuation to an Adjoining Building

Q: Our fire plan says if there were ever a fire in our hospital, we would evacuate our patients horizontally to the other side of the smoke barrier. It then goes on to say that if further evacuation is ever required, patients would be taken down a stair located on the other side of the smoke barrier. Once in the stair, patients would be taken to at least 2 floors below the fire floor. Some floors in our hospital connect with another building. My question is: Instead of moving patients down the stairs in the hospital, can we move patients horizontally into another building separated by a 2 or 3 hour fire rating? People have different opinions on this. Some say it’s a good idea to move into a different building because you don’t want to move patients down the stairs, while others say you should always stay in the building and evacuate using the building’s stairs because once you’re in the stair, you’re in a 2-hour fire rated enclosure anyway. Does NFPA reference/requirement on this? If not, what would you recommend?

A: I’m not aware of any reference in the NFPA codes or standards that discusses the virtues of evacuating into another building, but I know it is done in many other hospital organizations. I think it is always best to continue to evacuate horizontally if you can, rather than vertically down a set of stairs. If you’ve ever been involved in a training event where simulated patients were used to evacuate down the stairs, you will quickly agree that should be the last resort.

For those individuals who say you should stay in your own building and evacuate down the stairs, I would respond saying why? What advantage is there? Yes, the stairwell does provide a certain level of safety from the fire (i.e. a 2-hour barrier), but so does the 2-hour occupancy separation (or 2-hour building separation) that an adjoining building offers. For those who say you should never take inpatients into a non-healthcare occupancy, I say poppycock! (My English grandfather used to use that word a lot). A fire event is an emergency and during an emergency you do what is best for the patient.

Change your policies if they say you don’t evacuate horizontally into an adjoining building, but rather down the stairs. You do what you have to do during an emergency. It is assumed that the evacuation of an inpatient into an adjoining building that is not healthcare occupancy would be for a short period of time. The patient may still require a certain level of care that may not be provided in an ambulatory healthcare occupancy or a business occupancy. In those cases, the patient should continue be evacuated to a location where they can be cared for.

And don’t forget the elevators. While elevators are not permitted as a required means of egress, they can be a secondary means of egress, provided the elevator is not actively involved in the fire. Find an elevator away from the fire (even if it is in an adjoining building) and use the elevator to evacuate patients.

Evacuation Chairs in Stairwells

Q: I just got cited by the Joint Commission for having evacuation chairs at tops of our stairwells. The chairs were not causing any egress issues in my opinion, but the surveyor did not care that state fire marshal gave his blessing 8 years ago to have chairs at tops of stairwell and during the previous two Joint Commission surveys the chairs were not an issue. Your thoughts on this would be greatly appreciated.

A: First of all, it doesn’t matter what a state or local inspector or fire marshal says. Joint Commission and/or CMS does not have to comply with what a state or local authority says on an issue, and often does not care. All authorities having jurisdiction (AHJ) are equal, but separate. To have the permission or interpretation of one authority does not provide you with any leverage or influence with any other authority. Often times the authorities simply do not care what the other authorities say.

The Life Safety Code is not entirely clear on the subject of evacuation chairs mounted in stairwells. At one point (section 7.2.2.5.3 of the 2012 Life Safety Code) the code says no space in the exit enclosure may be used for any purpose that has the potential to interfere with egress. One may conclude that if the evacuation chairs are mounted off to the side of the top landing where there is no possibility of egress interference, then you can mount an evacuation chair there. But the code does not specifically say that and it would have to be an interpretation by the authority to allow it.

But section 7.1.3.2.3 also says an exit enclosure cannot be used for any purpose that has the potential to interfere with its use as an exit. According to the Annex section, the intent of this standard is the exit enclosure should be sterile with respect for fire safety hazards. The authorities can interpret this any way they want since the code is not clear.

Apparently, the Joint Commission (through the surveyor) is saying they will not allow it, and it is well within their right to say so. I have been in conferences where representatives from the Joint Commission engineering department say they do not allow stairwell evacuation chairs to be stored inside the stairwell.

Evacuation Chairs Stored in Stairwells

Q: I understand it would be best to not place something affixed to the walls of the exit stairwell that protrudes in to the path of egress, which in turn, may interfere with egress. But we have two sets of stairwells, that in the middle of each floor, is a landing which has about a 7’ alcove going away from the path of egress on the landing, and the path of egress does not use this alcove.

So my question is, can we store evacuation chairs in these alcoves? I can understand affixing these items in the path of egress within the stairwell, can interfere with egress, but these alcoves are clearly out of the way and not in the path of egress.

A: To answer your question, let’s first take a look at section 7.2.2.5.3 of the 2012 Life Safety Code (LSC), which says there shall be no enclosed, usable space within an exit enclosure, including under the stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

What this section appears to say is you may store your evacuation chairs in the alcove of your stairwell since the alcove is not part of the egress, and the stored evacuation chairs would not interfere with egress. But there are surveyors and AHJs that take a much more severe look at this issue, based on section 7.1.3.2.3 of the 2012 LSC, which says an exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

Some AHJs take a very strong stand against anything being stored in the stairwells, but the Annex section of 7.1.3.2.3 explains this requirement a bit further, and says the provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be ‘sterile’ with respect to fire safety hazards.

The above reference is in the Annex section of the LSC which means it is not part of the enforceable section of the code, but it is an explanatory section to help authorities understand the intent of the technical committee who wrote the code. Most AHJs follow what the Annex section says, although they do not have to. The Annex section for 7.1.3.2.3 does prohibit storage in the stairwell that is “not necessary for safety”, but one could make the point that evacuation chairs are necessary for safety and therefore are permitted to be stored in the stairwell, as long as they do not interfere with egress.

The bottom line is it is apparent to me that the Life Safety Code does permit the storage of evacuation chairs in an exit stairwell, as long as the chairs are stored in such a way as to not interfere with egress. However, not all AHJs actually agree with this and some do cite hospitals if they have anything stored in the stairwells. If you want to pursue this and store the evacuation chairs in the alcove of your stairwells, I suggest you document these sections of the Life Safety Code and show them to any surveyor who questions the practice. It may prevent you from having a citation, or it may not.

Evacuation Route Maps

Q: Are evacuation route maps required in a hospital? We have them in our facility, but I’ve heard some people say they are not required. If they are not required, why does our facility have them?

A: To quickly answer your question: No they are not required. According to the Life Safety Code (LSC) and other NFPA standards, evacuation route maps are not required, anywhere in your hospital. However, if you have evacuation route maps, the must be accurate and up to date. All too often the evacuation route maps are put into place and then forgotten, and changes and additions to the floor plans are not updated on the evacuation route maps. Also, the orientation of the evacuation route maps must be placed so anyone can easily discerned where they are in relation to the evacuation route map.

There is considerable value in having evacuation route maps. They can be a teaching aid when conducting fire drills on a unit. You can use the evacuation route map to identify the locations of key features of life safety, such as:

  • Smoke compartment barrier doors
  • Exits
  • Fire alarm pull stations
  • Medical gas shutoff valves
  • Fire extinguishers
  • Elevators

You are not alone in wondering why hospitals have evacuation route maps. At one time they were required by the fore-runner of the Centers for Medicare & Medicaid Services (CMS). Someone pointed out to them that the NFPA codes and standards do not require evacuation route maps, and CMS agreed and removed them from the requirements. But hospitals seem to hang onto them, probably because they are a good idea.

The confusion on this issue is from section 19.7.1.1 of the 2000 LSC which requires written copies of a plan for the evacuation to areas of refuge. The LSC is only referring to a written plan, like a management plan, but somehow it got interpreted to mean evacuation route maps.

Now, there may be other codes or standards that could require an evacuation route map that a hospital has to consider, so they should check with the local and state authorities.

Evacuation Route Maps

Q: Where in the Life Safety Code does it say evacuation route maps are required to be posted on the floors in a hospital?  I cannot find the reference and I have people saying they are not required.

A: Your people are right… the Life Safety Code does not require them. But then you may ask, why are they posted in many of the hospitals in the country? The answer is the NFPA 101 Life Safety Code (LSC) never required them. The reason so many hospitals thought they needed to post evacuation route maps is due to an incorrect interpretation by CMS (or the fore-runner of CMS: HCFA) in the 1990’s. If you look at section 18/19.7.1.1 of the 2000 LSC, it says the hospital must have a plan for the evacuation to areas of refuge and for the evacuation from the building in the event of a fire. Back in the 1990’s, this was miss-interpreted by the federal agency to require posted evacuation route maps, so hospitals put them up. Eventually, it was brought to CMS’s attention that the code does not require evacuation route maps, just a plan, and CMS agreed and removed the requirement form their inspection forms. But, the word did not get around very well, and hospitals continued to maintain them.

I think posted evacuation route maps are very useful and hospitals should consider using them. But, from a national authority level, they are not required.

Evacuation Route Maps

Q: Are evacuation route drawings required to be posted at nurse stations or anywhere else per Joint Commission or CMS requirements?

A: No. There is no Joint Commission standard or requirement and there is no CMS standard or requirement for evacuation route plans to be posted on units or in corridors. Although, having them in strategic locations are valuable teaching aids during routine fire drills. This is one of those great surveyor myths that seems to have been started decades ago by an misinterpretation by an official from CMS (or as it was called back then, HCFA). You may want to check with your local and state authorities to see if they have any requirements on this issue.

Evacuation Chairs

Q: Are stairway evacuation chairs required in all high rises, or business occupancies in general?

A: According to the Life Safety Code, there is no requirement to provide stairway evacuation chairs in any specific occupancy, hi-rise or otherwise. However, the Life Safety Code (as well as any of the Accreditation Organizations, such as Joint Commission, HFAP, and DNV) requires you to have a fire safety plan that includes plans for evacuation. If your organization chooses not to use stairway evacuation chairs to evacuate your patients, then you must have an alternative method to evacuate patients. Incidentally, the Life Safety Code does not restrict the storage of evacuation chairs inside a stairwell, as long as it does not interfere with egress. The only place that qualifies for ‘not interfering with egress’ is usually at the top of the typical stairwell. As always, please check with your state and local authorities to determine their regulations concerning evacuation chairs.

Items Stored in a Stairwell

photo 1 web 2We should all know that storage of items in an exit enclosure, such as a stairwell, is not permitted by the Life Safety Code. Right? Well… there are exceptions that would allow certain items to be stored in a stairwell, but not all of the authorities having jurisdiction (AHJ) actually recognize these exceptions.

I was recently asked if a hospital could store their evacuation chairs in the alcoves of a stairwell (see the picture to the left). The alcoves are not in the direct path of egress inside the stairwells and appear to have been designed to allow a overlook to the scenery outside the building.

So let’s take a look at section 7.2.2.5.3 of the 2000 LSC which says the following:

“There shall be no enclosed, usable space within an exit enclosure, including under the stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.”

This section makes it clear that you cannot have enclosed storage space in the exit enclosure, although the exception to this section does allow an enclosed storage underneath the stairs as long as it is separated by barriers with the same fire resistive rating as the exit enclosure and it is accessible from outside the stairs.

Another section (7.1.3.2.3 of the 2000 LSC) says the following:

 “An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.”

The Annex section of 7.1.3.2.3 says the following:

“The provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be ‘sterile’ with respect to fire safety hazards.”

What this section means is the storage of evacuation chairs would be permitted in the alcove of a stairwell since the alcove is not part of the egress, as long as the stored evacuation chairs would not interfere with egress. But there are surveyors and AHJs that take a much more severe look at this issue.

The above reference is in the Annex section of the LSC which means it is not part of the enforceable section of the code, but it is an explanatory section to help authorities understand the intent of the technical committee who wrote the code. Most AHJs follow what the Annex section says, although they do not have to. The Annex section for 7.1.3.2.3 does prohibit storage in the stairwell that is “not necessary for safety”, so one could make the point that evacuation chairs are necessary for safety and therefore are permitted to be stored in the stairwell, as long as they do not interfere with egress.

The bottom line is it is apparent that the Life Safety Code does permit the storage of evacuation chairs in an exit stairwell, as long as the chairs are stored in such a way as to not interfere with egress. However, not all AHJs actually agree with this and some do cite hospitals if they have anything stored in the stairwells. If you want to pursue this and store evacuation chairs in the alcove of your stairwells, I suggest you document these sections of the Life Safety Code and show them to any surveyor who questions the practice. It may prevent you from having a citation, or it may not.

Hotel Room Evacuation During Fire Alarm

Q: We own and operate a hotel on our hospital campus and are revamping our fire plan. Are we required to have all the hotel guests evacuate their rooms upon activation of the fire alarm? Also, we have a marked exit into a courtyard with a 6 foot high fence around it. The gate in the fence then leads to the public way. Must this gate remain unlocked for egress to the public way or can you have an assembly point inside the courtyard?

A: Section 29.7.4.2 of the 2000 Life Safety Code states the fire safety information that is posted in the hotel room is sufficient for the guests to make their own decision as to whether or not they evacuate their rooms and/or building during a fire alarm. In an obvious fire alarm testing situation, I can see that is a legitimate situation where evacuation is not necessary. But other than that, 29.7.4.2 appears to leave that decision up to the guests. However, it would seem logical to want everyone to evacuate whenever a fire alarm is activated.

In regards to the fence surrounding the courtyard, that presents other problems. Since you say it is a marked exit, then the exit discharge is required to extend to the public way. The public way is defined as a street, alley, or other similar parcel of land essentially open to the outside air, which is dedicated or otherwise permanently appropriated to the public for public use. A fenced-in area that has a locked gate does not seem to meet this definition of public way. In my opinion, the gate would have to remain unlocked. The gate would also have to be an obvious point of exit, or it would have to be marked with an illuminated exit sign, and the path of egress to the public way would need to be illuminated with emergency power. Even if you got a local authority having jurisdiction (AHJ) to allow the locked gate in the courtyard, that does not mean other AHJs would see it the same way.

Evacuation Route Maps

Q: We had a question as to whether or not we are required to have posted emergency evacuation route signage posted throughout the hospital and clinical buildings. Given the fact we have extensive exit lights in place throughout all buildings is there a Joint Commission requirement that the evacuation route be posted within the buildings?

A: No, there is no Life Safety Code, Joint Commission or CMS requirement to have emergency evacuation route maps posted in the hospital. As far as I can tell, there never has been a Joint Commission requirement of this, but at one time, the interpretation handed down to state CMS inspectors did require hospitals to post emergency evacuation route maps. It was determined that this was an incorrect interpretation on the CMS form 2876S (also called K-Tags) about 10 years ago, and CMS removed the emergency evacuation route map requirement from the K-Tags document. It is possible that the misinterpretation may have started with section 19.7.1.1 of the Life Safety Code (2000 edition) which requires hospitals to have written plans for evacuation from the building. No matter how the mistake was made, it is comforting to know the officials did the correction and now evacuation route maps are not mandatory, however they can be very helpful when they are accurate. Please check with your local and state authorities to see if they have any requirements to post evacuation routes.