Q: Can an FSES equivalency be written for an oversized ER suite? Our ER was constructed in 2005 and the designer made it 13,450 square feet, which is more than the maximum allowable amount. We have exam rooms without doors and a surveyor said that was not allowed if the ER is not a suite.
A: Yes, a Fire Safety Evaluation System (FSES) equivalency may be conducted and submitted to your authority having jurisdiction, but you have to make sure of a few issues. First, the deficiency for an over-sized ER suite has to address the fact that the exam rooms do not have doors. The surveyor is correct in saying that a room providing care or treatment to a patient has to be separated from the corridor by a door that latches. Secondly, since you do not qualify for a suite (because you are 3,450 square feet over the limit), you have to assess the ER as if it has an exit access corridor, and all the exam rooms are open to the corridor. The FSES document is a NFPA 101A Guide on Alternative Approaches to Life Safety (2001 edition), and the worksheet to use is form 4.7.6. The value for Safety Parameter #5 has to be -10 points for no doors to the corridor. Make sure you travel distances are no more than 100 feet or 50 feet if through two intervening rooms. If the plans to construct the ER department were approved by the local authority on construction after March 11, 2003, then you must assess the area on the FSES worksheet as new construction, which makes it harder to get the numbers to work. The logic on that issue is a new building should not have any life safety deficiencies. If the numbers do not work out on the FSES equivalency, you can always consider cutting the ER into two, smaller suites by adding doors and walls in strategic areas. That may not be desirable, but it may be your only solution if the FSES does not work.