Fire Alarm Pull Stations in an Outpatient Clinic

Q: We have an outpatient clinic which is a business occupancy and provides ancillary services like physical therapy and radiology, and there are no fire alarm pull stations in the building. Are we required to have a fire alarm system and if so, do we need pull stations?

A: According to section 39.3.4 of the 2000 edition of the Life Safety Code (LSC), there are multiple options that may or may not require pull stations. An automatic fire alarm system is required if the building is two or more stories in height above the level of exit discharge, OR there are 100 or more occupants above or below the level of exit discharge, OR there are 1,000 or more total occupants in the building. Therefore, if the building does not qualify for any of the above conditions, then a fire alarm system is not required and manual pull stations also would not be required. However, if your clinic does meet one of the requirements for a fire alarm system, then initiating devices are required by one of the following methods:

•      Manual pull stations, OR

•      Smoke detectors and heat detectors installed throughout the building, OR

•      Automatic sprinklers installed throughout the building that will initiate a fire alarm upon water-flow.

Therefore, it is possible that manual pull stations may not be required in your clinic if the building meets the exceptions listed in section 39.3.4. However, please check with your local and state authorities to determine if they have other requirements you need to comply with.

Disabled Pull Station

 I was at a hospital recently that was installing a completly new fire alarm system in their building. I came across the disabled pull station in the picture to the left, and noticed that there was a large piece of tape across the handle of the pull station.

The facility manager that I was with said that particular device was part of the new system and it was not activated yet. He pointed out that there was an old fire alarm pull station (which I had not noticed), located within a few feet of this device and it was still activated.

This is a very big advantage that I have over the facility managers: They are in their building day in and day out and they do not typically think like a person who has never been been inside the facility before. Since I noticed the disabled pull station first, it did not make me look for the other activated pull station, which was about 5 feet away. If there had been an actual fire emergency, it is possible that a person who is unfamiliar with the fire alarm upgrade to see the disabled pull station, and not necessarily notice the old activated pull station, and move on down the corridor in search of one that actually operates which would delay the activation of the fire alarm.

I suggested to the facility manager that he install a sign over the disabled pull station, stating this device was not activated and a description (with an arrow) describing where the closest active pull station is located. Since this particular hospital had established a procedure of posting all public signs in three languages (English, Spanish and Chinese) then this temporary sign would also have to have all three languages.

A surveyor or inspector could very well cite this hospital for failure of proper interim life safety measures, or at the very least, failing to identify all safety and security risks in the environment.

Construction Involving the Fire Alarm System

Q: Our projects team currently disables our fire alarm control panel each morning during periods of construction and restores the panel each evening. They do this to prevent unwanted fire alarms that would be a nuisance to our staff and local fire department. This doesn’t seem to me to be the best method to deal with construction and the fire alarm panel. Do you have any thoughts or suggestions on this topic?

A: Your message did not address whether or not Interim Life Safety Measures (ILSM) are implemented during the time the fire panel is disabled, and that would be my number 1 concern. Section of the 2000 edition of the Life Safety Code® (LSC) discusses alternative life safety measures acceptable to the authority having jurisdiction (AHJ) need to be in place whenever construction, repair, alterations or additions are in progress. Also, section requires the AHJ shall be notified and a fire watch be implemented (or evacuate the entire facility, which is not desirable) whenever the fire alarm system is out of service for 4 or more hours in a 24 hour period. Those are mandatory actions that need to be followed. Other option, in lieu of disabling the entire fire alarm system, is to just remove from service the specific detectors or initiating circuit in the construction area, although you would still have to follow ILSM procedures. Most modern fire alarm systems have the ability to program initiating devices out-of-service to allow construction activities. Another option is to physically remove the detectors from their bases if this is possible. Some hospitals place protective coverings over smoke detectors during time of construction, although I am not a supporter of that practice. I have seen multiple situations where someone forgot to remove the protective cover from the detector and it remained in place long after the construction was completed. The bottom line is this: You need to develop a plan for alternative measures that is acceptable with your AHJ, presumably the local fire department, whenever a feature of fire safety is impaired. You are also required to develop a ILSM policy with written criteria for evaluating when and to what extent you should follow special measures to compensate for an increase risk to life safety, if your are accredited by the Joint Commission.


Air Handler Reaction Time

Q:  Is there a minimum reaction time for an air handler to respond to a duct detector activation? We had a consultant say that we had to record documentation that includes both the time the duct detector was tested (start time) and the time that the air handler actually shut down. Is this true?

A: Well, the comment made by the consultant is partially correct. The Life Safety Code® (LSC) 2000 edition section requires compliance with section 9.6 which requires compliance with NFPA 72 National Fire Alarm Code (1999 edition). NFPA 72 section 1- does stipulate that the time delay between the activation of an initiating device (in this case, the duct detector) and the activation of a fire safety function (in this case the air handler shutdown) shall not exceed 20 seconds. However, if the device was installed after January 1, 2002, then the delay is reduced to 10 seconds. So, for this portion of the code, the consultant is correct, in that there is a predetermined amount of delay between the duct detector activation, and the shutting down of the air handler. This time delay must be met and should be recorded by the installing contractor when the equipment is originally installed or replaced. But once the equipment has passed its initial installation requirement that does not mean that the time delay must be recorded each time it is tested. NFPA 72 section 7-2.2 requires the fire alarm system to be tested according to Table 7-2.2 “Test Methods”. This table requires testing of fire alarm system devices to verify their correct operation, not their time required to initiate their correct operation. So, in summary, since Table 7-2.2 does not have a specific requirement to measure the time delay for the system function even though it was required at the time of installation, then the hospital is not required to measure that time delay during subsequent tests. However, they can if they wish, as the test methods found in Table 7-2.2 are considered minimum standards, but any AHJ who enforces NFPA standards does not have the authority to require the hospital to measure that time delay.

Fire Alarm Audible Notification Device Testing

Q: Are fire alarm notification appliances required to have annual sound level measurement testing? We had a consultant tell us that we are supposed to conduct the sound level testing annually, but we have not heard of this requirement. What have you seen in your travels?

A: Yes they are, but you may not have to do this annual testing. Let me explain: The 2000 edition of the LSC requires the fire alarm system to be tested according to NFPA 72, 1999 edition. Section 14 of Table 7-2.2 requires audible alarm notification appliances to have sound pressure levels measured with meters meeting ANSI standards. Furthermore, section 19 of Table 7-3.2 requires the frequency of this sound level measurement to be accomplished at the time the appliance is initially installed and annually, thereafter. However, the commentary in the NFPA Handbook for NFPA 72 says if the sound measurement levels comply with the requirements of the code at the initial installation, then the AHJ may deem further testing as unnecessary. The comments in a handbook are not part of the enforceable code, but the AHJs can use these comments as a guide in making their decisions. I contacted representatives from The Joint Commission and the Centers for Medicare and Medicaid Services and they both said they do not require annual sound level measurement testing on audible appliances.

However, I suggest you contact your local and state AHJs to see what their requirements are.

Fire Alarm System Used for Medical Emergencies

Q: We have our Code Blue medical emergency system tied into the hospital’s fire alarm system and the control panel is located next to the telephone operators. They will then be able to hear the Code Blue alarm and make the appropriate over-head page. We were told by a consultant that this combined use of the fire alarm system is not permitted. What do you say?

A: Not knowing what standards your consultant was referring to, I can say it is permitted according to the NFPA 101 Life Safety Code (LSC), provided you adhere to specific requirements. Section 18/19.3.4 requires compliance with section 9.6 which in turn requires the system to be installed according to NFPA 72-1999. In section 3-8.2 of NFPA 72, it permits the fire alarm system to share components, equipment, circuitry, and installation wiring with non-fire alarm systems. Other requirements for a combined system, are:

  • Short circuits, open circuits, or grounds in the equipment and wiring shall not interfere with the monitoring for integrity of the fire alarm system, nor shall it prevent alarm or supervisory signals from being transmitted
  • The maintenance or failure of any component or software shall not impair the integrity of the fire alarm function
  • Overhead speakers used as alarm notification appliances on the fire alarm system shall not be used for nonemergency purposes, with some exceptions
  • The fire alarm signal shall be distinctive, clearly recognizable, and take precedence over any other signal even when a non-fire alarm signal is initiated first
  •  If the Authority Having Jurisdiction (AHJ) determines that the information being displayed or annunciated on a combination system is excessive and is causing confusion and delayed response to a fire emergency, the AHJ shall be permitted to require that the display or annunciation of information for the fire alarm system be separate from and have priority over information for the non-fire alarm      systems
  • All of the equipment used and installed in the combined system must be listed for the purpose for which it is used

If your combined system can meet these requirements, then it is permitted under the LSC. However, please check with your local and state authorities for any differing opinions.


Fire Alarm Transmission Times

Q: What is the requirement in time that a fire alarm needs to be transmitted to the fire department? Our fire alarm communication automatic dialer takes nearly 3 minutes to transmit an alarm to the monitoring company, and we are concerned this is too long.

A: Section 19.3.4 (18.3.4 for new construction) of the LSC requires the fire alarm system in the hospital to comply with section 9.6, which in turn requires the fire alarm system to be installed, tested and maintained according to NFPA 72 National Fire Alarm Code (1999 edition). Section 5- of NFPA 72 requires the digital transmitter (automatic dialer) to communicate with the digital receiver at the monitoring company in no more than 90 seconds. NFPA 72 requires the transmitter to retry a minimum of 5 times and a maximum of 10 times if the dialer fails to communicate with the receiver. Each retry is only allowed 90 seconds as well. According to 5- and A.5- the time to transmit the alarm signal from the monitoring company (central station) to the local fire responding unit (fire department) also is 90 seconds. You may be cited by an AHJ if the signal transmission process takes more time than allowed.

Smoke Detectors Used for Door Release

Q: In our hospital, we have smoke compartment doors in the corridor that are held open with magnetic hold-open devices. When the fire alarm system is activated, the magnetic devices release and the doors automatically close. Are we required to have smoke detectors located within 5 feet of these doors, even though the smoke compartments on either side of the doors are fully protected with smoke detectors?

A: The Life Safety Code (2000 edition) requires your fire alarm system to be in compliance with section 9.6 which further requires compliance with NFPA 72-1999 National Fire Alarm Code. Section 2-10.6 of the National Fie Alarm Code states that smoke detectors that are part of an open area protection system that is covering the room, corridor or enclosed space on each side of the smoke door and that are located and spaced according to NFPA 72-1999, section 2-3.4, shall be permitted to accomplish smoke door release service. Therefore, if your smoke detectors actually meet the spacing requirements found in 2-3.4 on both sides of the smoke door, then you do not need to have a smoke detector mounted within 5 feet of the door to release the door in the event of an alarm.

Smoke Detectors in Hospitals

Q: Are smoke detectors required to be installed in the corridors of hospitals? I attended a seminar recently and the instructor said we did not need them in the corridors. We have them in corridors and patient sleeping rooms in our hospital and I thought the Code required them.

A. Generally speaking, the Life Safety Code (LSC) does not require smoke detectors to be installed in corridors or patient sleeping rooms of hospitals. (You need to be sure what your state and local codes require for smoke detection, as those building codes may have a different requirement than the LSC.) Actually, for hospitals, smoke detectors are only required in strategic locations to satisfy specific needs of fire safety features, and to compensate for other deficiencies where an equivalency is being sought.

The LSC does require smoke detectors within 5 feet of a fire rated or smoke compartment door that is held open by a mechanical device (, in elevator lobbies and machine rooms where Phase I elevator recall has been installed (, and in areas permitted to be open to the corridor that do not have direct supervision ( In certain applications of, the corridor may need smoke detectors installed. The NFPA 72 National Fire Alarm Code does require a smoke detector above the fire alarm control panel in order to protect the panel in the event of a fire.

Equivalencies, such as the Traditional Equivalencies and the NFPA 101A Guide on Alternative Approaches to Life Safety Fire Safety Evaluation System (FSES), frequently rely upon smoke detectors to be installed throughout a smoke compartment to compensate for a deficiency to a life safety feature. When an equivalency is accepted by an Authority Having Jurisdiction (AHJ), the compensating changes (such as the installation of smoke detectors) must remain until the equivalency is no longer valid.

Limited care facilities (which are not hospitals) do have a requirement for smoke detectors in corridors ( and new nursing homes are required to have smoke detectors installed in corridors ( and patient sleeping rooms with certain combustible items, but these requirements do not apply to hospitals. The logic behind this LSC decision is a fire will be discovered quickly in hospitals where the staffing level is much higher. Remember: The requirements of the LSC are minimum requirements, and it is perfectly acceptable to exceed these minimum requirements.

Evacuation During a Fire Alarm

Q. Should a free standing medical office (business occupancy) be required to evacuate everyone when an alarm is pulled?  In this situation the building is a single story and has a sprinkler system.

A. Yes, generally speaking, occupants in free standing medical offices should evacuate the building whenever the fire alarm is activated, unless there are extenuating circumstances, such as testing of the fire alarm system has been announced. There are multiple references that support this requirement.

One of the goals of the NFPA 101-2000 Life Safety Code (LSC) is to provide for a reasonably safe movement of people in the event of an emergency, as identified in section 4.1.2. That supports the concept of keeping the occupants safe from fire and maintaining a safe egress from the building. Since the building you described is a business occupancy, chapter 39 of the LSC applies. Section 39.7.1 discusses the requirements for fire drills which applies to buildings with occupants of 500 or more, or 100 occupants above or below the level of ext discharge. Even if your building may not meet this occupant load requirement, you may have other fire drill requirements from another Authority Having Jurisdiction (AHJ), such as Joint Commission or your local fire marshal.

Section 39.7.1 refers to section 4.7 which discusses in detail about evacuation and relocation. The whole purpose of conducting fire drills is to prepare and train your staff for the proper response when an actual fire occurs. Therefore, the occupants in your free-standing medical office will need to evacuate from the building whenever the fire alarm activates under non-testing conditions.

It is better to get the people out safely and then determine what caused the alarm. It should be noted here, that you are not required to evacuate patients during a fire drill. During a drill, staff needs to demonstrate that they know and understand the procedures and pathway to evacuate the building and where the relocation rallying point is at once they get outdoors. They can use simulated patients or other staff members playing the role of patients to demonstrate this knowledge during drills.

This concept of evacuating the building in the event of fire does not apply to all occupancies, however. Most notably: healthcare occupancies (hospitals, nursing homes) and detention or correctional occupancies (prisons) have language that requires staff to be trained in the relocation of occupants to areas of refuge or smoke compartments.