Mar 02 2018

Doors to Operating Rooms

Category: BlogBKeyes @ 12:00 am
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Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that open to the corridor, and each has a 3’0″ door in the rear of the OR that opens into a central sterile core. The OR walls other than the corridor side are not labeled as a fire/smoke barrier on the life safety drawings. The main OR entrance door that opens into the corridor has a door closer, is rated, and has latching hardware. My question is: The 3′ 0″ doors opening into the sterile core have closers but do they have to be fitted with latching hardware?

A: Not necessarily, provided the sterile core area is qualifies as a room or a suite-of-rooms. What does the life safety drawings say about the sterile core area? Is it classified as a suite? If so, then you should be fine without a latching door between the OR and the sterile core area.

However, if the life safety drawings clearly identify the internal walls of the sterile core area as corridor walls, then the door between the OR and the sterile core area would have to latch. Remember: All corridor doors must latch.

My guess is, the sterile core area probably qualifies as a suite-of-rooms (see section 19.2.5.7 in the LSC) or if small enough, it may qualify as a simple room. As long as the 3’0” door from the OR does not open onto a corridor, then it does not need to latch.

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Jan 05 2018

Corridor Doors

Category: BlogBKeyes @ 12:00 am
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Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?

A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage.

I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency. Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in the corridor. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.

You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.

I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustible stored in those patient rooms, you have a big problem. The room would have to comply with section 43.7.1.2 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.

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Sep 05 2017

Power Assist Door

Category: BlogBKeyes @ 12:00 am
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Q: We were cited during a recent survey for not having our power assist doors to our ICU suite connected to the fire alarm system. I thought that was only required on fire-rated doors. Is this a requirement for a corridor door?

A: Section 7.2.1.9 of the 2012 Life Safety Code is discussing Powered Door Leaf Operation, and applies to power assist and power operated doors. This section is not limited to any type of door, such as fire-rated, smoke-resistant, etc. This section applies to all doors with power assist and/or power operated. The six criterions listed under 7.2.1.9.2 must all be met in order to comply with 7.2.1.9.2. Subsection (4) under 7.2.1.9.2 discusses the situation where the door leaf is required to be self-closing or positive latching and is equipped with power operation and is left in an open position, there must a smoke detector near the door that would activate and cause the door leaf to close and cease operation. Therefore, the power assist function would have to be connected to the fire alarm system. Subsection (4) says the smoke detector must be placed in accordance with NFPA 72, so there are a couple of options:

  1. A smoke detector within 5 feet on one side of the door if the height of the transom above the door is less than 24 inches.
  2. A smoke detector within 5 feet on both side of the door if the height of the transom is 24 or more inches above the door.
  3. A smoke detector within 14 feet of the door if the entire area on that side of the door (i.e. corridor) is 100% smoke detected.

All of the above applies to any door, regardless of fire-rating, that is required to be either self-closing or positive latching and is equipped with power assist or power operated equipment. Yes… it applies to suite entrance doors, because the suite is a room that is separated from the corridor and according to 19.3.6.3.3, corridor doors must latch.

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Jan 02 2017

Addressing Common Misconceptions Regarding Corridor Doors

Category: BlogBKeyes @ 12:00 am
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Corridor doors are one of the most common components of the means of egress, yet their significance is often overlooked, possibly because there are so many of them in a hospital. This article will address the different concerns and issues surrounding corridor doors in a healthcare occupancy that may not be considered common knowledge.

The Life Safety Code (LSC) does not require corridor doors to patient rooms to have closers, but if they do have closers, then they can have the type that have hold-open friction-catch closer arms, that requires someone to physically close them.  Hospitals are defend-in-place facilities, so the question asked by some is why do we rely on people to accomplish the closing of the door rather than allow a closer to do it?

As mentioned, corridor doors to patient rooms are not required to have closers, and this is in accordance with section 19.3.6.3.11 of the 2012 LSC. But the Annex section of 19.3.6.3.5 says 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.

Which brings us to the issue of those patient room corridor doors that have signage added, and coat hooks applied; would they be considered acceptable?

Coat hooks on a non-fire rated patient room corridor doors would be allowed. But a coat hook on a fire-rated door typically would not be acceptable (even if it is applied with adhesives) because any garments hanging from the coat hook would likely contribute to the fuel load of the door. But signage that was informational (i.e. contact precautions; oxygen administered; diet restrictions, etc.) would be permitted, even if they were combustible.

Are corridor doors that are located in a 1-hour fire barrier permitted to be only fire-rated for 20 minutes and not ¾-hour? The answer is no. If a corridor door is part of a fire-rated barrier that serves some other function, such as a vertical opening, exit, or hazardous area, then it must meet the most restrictive requirements of either. But where corridor doors are located in a 1-hour fire-rated barrier the corridor door must be at least a ¾ hour fire rated door, mounted in a fire-rated frame, with self-closing and positive latching hardware. Vertical openings are elevator shafts, mechanical shafts, stairwells, and the like. Exits are direct exits, horizontal exits and exit passageways. Hazardous areas are storage rooms >50 sq. ft. containing combustibles, soiled utility rooms, fuel-fired heater rooms, laundries >100 sq. ft., paint shops, repair shops, trash collection rooms, laboratories, and medical gas rooms (storage rooms with >3,000 cubic feet of compressed gas).

There is one exception to the above rule where a corridor door located in a 1-hour fire rated barrier must be ¾ hour fire rated: When the corridor door is also located in a 1-hour barrier separating the corridor from an atrium. According to section 8.6.7 (1) of the 2012 LSC, the atrium must be separated from adjacent areas with a 1-hour fire rated barrier, but the openings in the 1-hour fire rated barrier are only required to be same as is required for corridors. This means the doors in the atrium separation could be non-rated and only required to resist the passage of smoke, since atriums are only permitted in fully sprinklered buildings.

However, I don’t see where a patient room door would be part of any of these fire-rated barriers, although a patient room door could be part of a smoke barrier, separating smoke compartments. Even though the smoke barrier is required to be 1-hour rated, it is not a fire rated barrier, because the doors in a smoke barrier are only required to be 1¾ inch thick, solid-bonded, wood core doors, or of such construction to resist fire for at least 20 minutes, and must be self-closing. They are just like corridor doors in a non-sprinklered smoke compartment, but must have closers on them.

It’s important to realize that not all corridor doors have to meet the NFPA 80 requirements for fire-rated doors. However, if the corridor door is a fire-rated door, it must be compliant with the requirements of NFPA 80. If the door has a fire rated label, then it is a fire-rated door, and it must be mounted in a fire-rated frame, equipped with a self-closing device, and have positive latching hardware.  The problem that I observe in many hospitals is they installed labeled fire-rated doors in walls and barriers that are not fire rated. Therefore, even though the wall or barrier is not required to have a fire-rated door, the fact that the door is fire-rated means the organization must maintain it as such, according to section 4.6.12.3 of the 2012 edition of the LSC. So, if you have a fire-rated door in a corridor wall, and the corridor wall is not required to be fire-rated, then you must still maintain the fire-rated door to the requirements of NFPA 80, which includes annual testing.

Where I often find this problem in hospitals is the smoke compartment. Some designer/architect sees that smoke barriers are required to be 1-hour rated so they specify ¾ hour fire rated doors. Again, a smoke compartment barrier wall is not a fire-rated wall; therefore, the conditions of 19.3.7.6 apply where 1¾ inch thick, solid-bonded, wood-core doors are allowed. Also, some designers/architects see that smoke barrier doors that are of such construction that resists fire for at least 20 minutes are permitted, so they specify 20-minute fire rated doors for smoke barrier openings. Again, this is not required to have fire-rated doors, but since the 20-minute fire-rated doors was installed, you must maintain it to NFPA 80 requirements, which means it must be mounted in a fire rated frame, be self-closing, and positive latching. I see a lot of 20-minute fire rated doors in smoke compartment barriers that do not have positive latching hardware, which is non-compliant with NFPA 80. The organization must maintain the door to NFPA 80, or simply remove the fire rated label, then the door is no longer a fire-rated door that is obvious to the general public, and does not need to be maintained as such.

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May 04 2016

I’m Sorry…

Category: BlogBKeyes @ 12:00 am
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Dear Readers…

In a recent post I made a comment that architects are making errors and causing facility managers headaches by calling for 20 minute fire-rated doors in smoke barriers. I was wrong to have said that. While NFPA allows non-rated 1.75 inch thick solid-bonded, wood core doors in smoke barriers; the IBC does not.

Architects have to design the facilities to meet not only NFPA requirements, but often times they have to design to meet IBC requirements as well. The most restrictive requirement must be met, and the IBC requires 20-minute fire rated doors in smoke barriers.

My comment was rather derogatory towards architects, and for that I do apologize. I was allowing my frustration with poorly designed hospitals regarding suites-of-rooms to over-shadow my objectivity with the smoke barrier door issue. I will attempt to be more understanding and fair in the future.

Be assured that this website is intended to discuss NFPA codes and standards as it relates to healthcare facilities, and does not attempt to discuss or reference any other codes or standards. This is because once the facility is constructed, the facility manager is under siege with inspections from multiple authorities that hold them accountable to NFPA codes and standards; not the IBC.

Thank you….

Brad Keyes

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Feb 22 2016

The Final Question on Corridor Doors

Category: BlogBKeyes @ 12:00 am
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Q: Are all types of corridor doors exempt from having to meet the requirements of NFPA 80?

A: The answer is no. If the corridor door is a fire-rated door, it must be compliant with the requirements of NFPA 80. If the door has a fire rated label, then it is a fire-rated door, and it must be mounted in a fire-rated frame, equipped with a self-closing device, and have positive latching hardware.  The problem that I observe in many hospitals is they used labeled fire-rated doors in walls and barriers that are not fire rated. Therefore, even though the wall or barrier is not required to have a fire-rated door, the fact that the door is fire-rated means the organization must maintain it as such, according to section 4.6.12.2 of the 2000 edition of the LSC. So, if you have a fire-rated door in a corridor wall, and the corridor wall is not required to be fire-rated, then you must still maintain the fire-rated door to the requirements of NFPA 80. Where I often find this problem in hospitals is the smoke compartment. Some designer/architect sees that smoke compartment barriers are required to be 1-hour rated so they specify ¾ hour fire rated doors. Again, a smoke compartment barrier wall is not a fire-rated wall, therefore, the conditions of 19.3.7.5 apply where 1¾ inch thick, solid-bonded, wood-core doors are allowed. Also, some designers/architects see that smoke compartment doors that are of such construction that resists fire for at least 20 minutes are permitted, so they specify 20-minute fire rated doors for smoke compartment openings. Again, this is not required to have fire-rated doors, but since the 20-minute fire-rated doors was installed, you must maintain it to NFPA 80 requirements, which means it must be mounted in a fire rated frame, be self-closing, and positive latching. I see a lot of 20-minute fire rated doors in smoke compartment barriers that do not have positive latching hardware, which is non-compliant with NFPA 80. The organization must maintain the door to NFPA 80, or simply remove the fire rated label, then the door is no longer a fire-rated door that is obvious to the general public, and does not need to be maintained as such.

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Feb 15 2016

What… More on Corridor Doors?

Category: BlogBKeyes @ 12:00 am
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Q:  These corridor doors (i.e. patient rooms); if they are in a 1-hour fire barrier then is it okay for them to only be rated20-minute and not ¾ hour?

A: The answer is no. If a corridor door is part of a fire-rated barrier that serves some other function, such as a vertical opening, exit, or hazardous area, then it must meet the most restrictive requirements of either. In the scenario that you mentioned in your question, the corridor door must be at least a ¾ hour fire rated door, mounted in a fire-rated frame, with self-closing and positive latching hardware. Vertical openings are elevator shafts, mechanical shafts, stairwells, and the like. Exits are horizontal exits and exit passageways. Hazardous areas are storage rooms >50 sq. ft. containing combustibles, soiled utility rooms, fuel-fire heater rooms, laundries >100 sq. ft., paint shops, repair shops, trash collection rooms, laboratories, medical gas rooms (storage rooms with >3,000 cubic feet of compressed gas), and gift shops. I don’t see where a patient room door would be part of any of these fire-rated barriers. However, a patient room door could be part of a smoke compartment barrier. Even though the smoke compartment barrier is required to be 1-hour rated, it is not a fire rated barrier, because the doors in a smoke compartment barrier are only required to be 1¾ inch thick, solid-bonded, wood core doors, or of such construction to resist fire for at least 20 minutes, and must be self-closing. They are just like corridor doors, but must have closers on them.

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Feb 08 2016

Still More on Corridor Doors

Category: BlogBKeyes @ 12:00 am
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Q: Do you think adding tons of signage, and coat hooks would be acceptable on a patient room door?

A: Well…. That depends. Coat hooks on a non-fire rated door? Yes, that would be allowed. Tons of signage? That depends… if the signs were considered ‘decorations’ then section 19.7.5.4 of the 2000 LSC applies and combustible signs that are considered decorations would not be permitted. Signs that were informational (i.e. contact precautions; oxygen administered; diet restrictions, etc.) would be permitted, even if they were combustible.

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Feb 01 2016

More on Corridor Doors

Category: BlogBKeyes @ 12:00 am
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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).

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Jan 25 2016

Corridor Doors

Category: BlogBKeyes @ 12:00 am
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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.

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