Patient Room Doors in a Suite

Q: In a newly designated ICU suite, do the doors to the patient rooms have to be positive latching?

A: No… The doors to patient rooms that are located inside a suite are not required to positively latch. The reason for this; the requirement for a door to latch for a patient room is found in section 19.3.6.3.5 of the 2012 LSC when the door is a corridor door. A corridor door separates the corridor from a room or an area, such as a patient room. However, in a suite there are no corridors… what appears to be a corridor is actually a communicating space. Therefore, there is no requirement for doors to patient rooms to positively latch inside a suite. Actually, there is no requirement for doors inside a suite to patient rooms, which is quite common in Pre-Op, Post-Op, ER, and some ICUs.

Barriers Separating Suites

Q: We have two adjacent suites that are not separated by a smoke wall. My question is; does a door along that separation have to meet the requirements of a smoke door? The door does not open into a corridor, it is only separating the two suites. Also, should that suite separation barrier be a smoke wall all alone the separation?

A: There are requirements for the barrier that separates two adjacent suites, but the phrase you use “smoke wall” is not the correct description. According to section 19.2.5.7.1.2 of the 2012 Life Safety Code, the barrier that separates suites from other suites (and the barrier that separates suites from all other areas of the hospital), must be equal to the construction of the existing corridor walls as described in 19.3.6.2 through 19.3.6.5. This means, if your corridor walls are permitted to be non-rated smoke resistant and extend from the floor to the ceiling, then that means the barrier separating the two suites must be as well. However, if your corridor walls are required to be ½ hour fire rated and extend from the floor to the deck above, then that is also the requirement for the barrier separating the two suites. In both cases, the door between the two suites would have to resist the passage of smoke and be positive latching, but is not required to be fire-rated or self-closing. You use the phrase “smoke wall” which is ambiguous. That is not a NFPA term. According to NFPA, there are smoke partitions (i.e. corridor walls, non-rated hazardous room walls) and there are smoke barriers (i.e. barriers that separate smoke compartments), and there are different requirements for both.

Suite Entrance Doors

Q: A hospital has 2 different suites with double egress entry doors and the Joint Commission surveyor noted that these doors are supposed to have latching hardware because they are “corridor doors,” but in my experience, cross-corridor doors are not typically required to have latching hardware.  Can you weigh in on this?

A: I agree totally with the surveyor. According to the LSC, suites are nothing more than rooms; albeit a large room with smaller rooms inside. Therefore, corridor entrance doors to suites must positively latch because corridor doors are required to latch according to 18/19.3.6.3.5, 2012 LSC.

The thing that throws people off is what looks like a corridor inside a suite is not a corridor; it is a communicating space. The requirements of a corridor do not apply inside a suite. But the designers often make this space 8 feet wide and for all intent and purposes people think it is a corridor. Then, the designer places double egress doors as entrances to the suite (which is good when you’re pushing patients in an out on beds) and the doors look like cross-corridor doors. They’re not; they are corridor doors.

The hospital has to make those doors positively latch or they have to change the designation from a suite to a corridor, which is not advisable.

Suite Entrance Doors

Q: We have a double egress, cross-corridor door which will enter a suite under a renovation project. The suite wall is also an existing smoke barrier wall, separating smoke compartments. However, we do not want an exit route through the suite, as this would be a code violation. The new layout will not cause a dead-end corridor and the suite will house less than 50 people. Is it allowable to replace the double egress door with a pair of out swinging doors?

A: As long as the new doors are not cross-corridor doors, I believe you can have a pair of single-egress doors as an entrance to the suite in a smoke compartment barrier. Under section 18.3.7.6 of the 2012 LSC, all new cross-corridor doors serving a smoke compartment barrier must be the double egress type. But from your description, it appears these new doors would not be cross-corridor doors, but would be corridor entrance doors to the suite.

These new doors would have to latch because they are corridor entrance doors to a suite, even though they serve a smoke compartment barrier.

Suite Boundary

Q: We have a suite inside of a smoke compartment. We are trying to find out if the dividing wall needs to be the same as the 1-hour smoke barrier.

A: According to section 19.2.5.7.1.2 of the 2012 LSC, the boundary of a suite has to meet the requirements for corridors. This means, if the smoke compartment is not fully protected with sprinklers, then the corridor walls must be 30-minute rated, smoke-resistant, and extend from the floor to the deck above. If the smoke compartment is fully protected with sprinklers then the corridor walls only have to be smoke-resistant and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke. Therefore, the suite perimeter walls would have to be the same as the corridor walls.

It is possible however, that one wall can serve two purposes, so the suite wall could also be a smoke barrier as long as the wall meets the requirements for both purposes.

Keep in mind that a suite is nothing more than a room, although it is a large room with a lot of smaller rooms inside. Therefore, all corridor entrance doors into the suite must positively latch, and the path of egress cannot take you from a corridor into a suite to get to an exit.

Sleeping Suites

Q: Are recovery rooms and observation units considered sleeping suites or non-sleeping suites? What is the definition of what constitutes a sleeping suite?

A: Recovery rooms, surgical suites and pre-op suites would be considered “non-sleeping suites” because sleeping accommodations are not provided in these areas. The Life Safety Code uses the term “patient sleeping rooms”. If the suite includes patient sleeping rooms, then it is restricted to the requirements for sleeping suites. If the suite does not provide sleeping rooms, then it can be considered non-sleeping suites which have less restrictions.

An observation room can be a patient sleeping room, or it can be an exam room in an ER. Whether it is classified as a “patient sleeping room” depends on the hospital’s definition of an observation room. Remember: If it looks like a duck and quacks like a duck, then it pretty much is a duck. If the observation room looks like a patient sleeping room, then a surveyor can consider it a patient sleeping room even if you call it something else.

Surgery Suites

Q: Are surgery rooms considered to be patient sleeping rooms or non-sleeping rooms? In reference to allowable suite sizes, what is the maximum area of the suite?

A: Surgery rooms are definitely considered non-sleeping rooms. A sleeping room is a room designed and constructed for patient sleeping. Surgery rooms are not designed and constructed for patient sleeping. And by the way, (you didn’t ask, but….) neither are sleep labs. A sleep lab sleeping room is not a patient sleeping room, but is an exam room, and can qualify to be classified as business occupancies. Since it is a non-sleeping area, a surgery suite is permitted to be 10,000 square feet in size. However, if you had a patient sleeping suite, the 2000 Life Safety Code limits the size to 5,000 square feet. The 2012 Life Safety Code does permit patient sleeping suites to extend to 10,000 square feet but specific additional requirements have to be met. There are CMS categorical waivers that would allow a hospital to utilize the 2012 edition pertaining to patient sleeping suites.

Suite Definition

Q: I can’t seem to find the definition of a suite in the Life Safety Code. What defines a suite?

A: Think of a suite as nothing more than a large room, with a lot of smaller rooms inside. You’re correct in saying the 2000 edition of the Life Safety Code does not define a suite, but the 2012 edition has. That edition says a suite is: “An accommodation with two or more contiguous rooms comprising a compartment, with or without doors between such rooms, that provides sleeping, sanitary, work, and storage facilities.” And: “A series of rooms or spaces or a subdivided room separated from the remainder of the building by walls and doors.” There are different types of suites:

  • Non-patient care suites
  • Patient care non-sleeping suites
  • Patient care sleeping suites
  • Patient care suite
  • Currently, the 2000 edition of the LSC limits suites to the following sizes:
  • 5,000 square feet for patient care sleeping suites
  • 10,0000 square feet for non-patient sleeping suites
  • The 2012 edition has relaxed those limitations on suites, and hospitals are permitted to adopt that section of the 2012 Life Safety Code through the CMS categorical waivers. Since the suite is considered a room (no matter how large it is), it is subject to the rules and regulations that concern all rooms, mainly:
  • It must be separated from the corridor by appropriate corridor construction, including doors and windows
  • Entrance doors to the suite from the corridor must positively latch
  • Egress from the corridor, into the suite to get to an exit, is not permitted

Suite Wall Construction

Q: I cannot find anywhere in NFPA on the wall construction of a suite wall. We’ve been building them as a smoke wall but the code doesn’t say anything.

A: You are correct… the NFPA Life Safety Code 2000 edition does not address the construction of the suite walls… directly. However, it does have something to say about it, in a round-about manner.

A suite is nothing more than a room, albeit a very large room with many smaller rooms inside it; but nonetheless, the suite is a room. Sections 18/19.2.5 (of the 2000 edition of the Life Safety Code) discusses the arrangement of the means of egress and how it relates to rooms. In this section, the terminology that the Life Safety Code uses, includes ‘room’ and ‘suite’ interchangeably. This section also uses the term “Suite of rooms”, which further reinforces the concept that a suite is a room. So, the conclusion is: If a suite is a room, then it must be protected in the same fashion as a room.

Sections 18/19.3 (same 2000 edition) discusses the requirements for protection, and sections 18/19.3.6 discuss the needs to protect corridors. Sections 18/19.3.6.1 says “Corridors shall be separated from all other areas by partitions…” So, what are the “other areas” that 18/19.3.6.1 is talking about? Rooms. Or more to the point for our discussion: Suites. Sections 18/19.3.6.2 discuss how the corridor walls are to be constructed; sections 18/19.3.6.3 discusses the requirements for corridor doors; and so on.

So, the construction requirements for walls separating suites from the corridors is covered under section 18/19.3.6. But that does not cover the construction requirements for walls separating suites from other areas other than corridors; such as other suites; or other rooms that are not part of the suite; and so forth. The 2000 edition of the Life Safety Code is rather silent on that subject, so the authorities having jurisdiction (AHJ) pretty much made an interpretation, and decided that the construction of the walls separating a suite from areas other than the corridor, must be the same as the construction requirements for a corridor wall. Not all the AHJs, but the AHJs that are national accreditors on healthcare pretty much came to this conclusion on their own

This made good sense, to the point that, when the 2012 edition of the Life Safety Code was created, the Technical Committee decided that should be placed in the actual code itself; so they did. Take a look at section 19.2.5.7.1.2 in the 2012 edition of the Life Safety Code:

“Suites shall be separated from the remainder of the building, and from other suites, by one of the following:

  • Walls and doors meeting the requirements of 19.3.6.2 through 19.3.6.5
  • Existing approved barriers and doors that limit the transfer of smoke”Section 19.3.6.2 through 19.3.6.5 is the section on corridor wall construction.So, a short and sweet answer to your question is: The walls for a suite need to conform to the requirements for corridor walls.

Section 19.3.6.2 through 19.3.6.5 is the section on corridor wall construction.

So, a short and sweet answer to your question is: The walls for a suite need to conform to the requirements for corridor walls.

Suite Entrance Doors

Q: Are there any NFPA regulations which require doors serving as exits from suites must swing in the direction of egress? I have identified smoke barrier double doors in corridors which seem to fit the description of “cross corridor doors” and found to swing in the same direction. Upon review of NFPA 18.3.7.5 it seems as though they must swing in opposite directions. Will these doors have to be replaced or modified to swing in opposite directions?

 A: Yes, there are NFPA regulations that address door swings in the direction of travel, but it depends on different factors and not all suite entrance/exit doors would have to comply. Section 7.2.1.4.2 of the 2000 edition of the Life Safety Code specifically says doors required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel where serving a room or area with an occupant load of 50 or more. An exception to this requirement says smoke barrier doors shall not be required to swing in the direction of egress travel as provided in Chapter 19. So this section only requires doors to swing in the direction of egress where the occupant load is 50 or more. As far as the Life Safety Code is concerned, the occupant load is calculated by the defined occupant load factor and the area of the space involved. So, an inpatient treatment suite such as an ICU, which has a maximum area of 5,000 square feet and the occupant load factor for healthcare sleeping area is 120 square feet per person (see Table 7.3.1.2), would have an occupant load of 41 persons. So, based on those factors an entrance/exit door from an ICU suite would not have to swing in the direction of egress travel. The exception to 7.2.1.4.2 permits existing smoke compartment barrier doors to be exempt from this requirement, so if the cross-corridor doors that you have identified were installed prior to March 11, 2003, then they are considered existing and are exempt from having to swing in the direction of egress travel. Why March 11, 2003? That’s the date CMS adopted the 2000 edition of the LSC. It is important to point out section 7.2.1.4.3 which requires the door to swing in the direction of egress travel where used in an exit enclosure. Therefore, a door leading into an exit stairwell would have to swing in the direction of egress travel regardless of how few occupants it serves. You are correct that 18.3.7.5 does require new smoke compartment barrier cross-corridor doors to be a pair of opposite swinging doors, but that just for new construction, or anything built on or after March 11, 2003. If by chance the smoke compartment barrier cross-corridor doors in question are new (installed on or after March 11, 2003) and they are not double egress, then that would be a LSC deficiency. The organization could choose to replace the doors with compliant ones; or request a waiver or an equivalency from CMS which probably would not be approved. My suggestion is that you just repair the doors and make them double egress swing.