Lactation Pods

Q: Our hospital recently purchased a few lactation pods like they have in airports. I can’t help wondering if they need to have fire alarm notification devices and sprinklers. Has this been issue with any accreditation surveyors yet?

A: I can’t say that I’ve given this subject much thought. I am not aware that any surveyors have cited this issue so far.

It would be my thinking that a Lactation Pod would be similar to the concept of a clothes closet as described in section 19.3.5.10 of the 2012 LSC whereas sprinklers would not be required. But there is a maximum area allowed under that section of 6 square feet, and I don’t know if the Lactation Pod is under 6 square feet.

I did contact CMS and asked them if they would require sprinklers in these pods and they replied in an informal communication and said they agreed that the lactation pods would be considered comparable to a portable wardrobe unit and would not require sprinklers to be installed in the pod.

Sprinkler Support Hangers

Q: We are building a new ER and an area of the existing building had to have some work done so that the new ER could connect to the old building. The existing ceiling was a “hard” ceiling and the existing sprinklers were hung below the ceiling. We now have a drop ceiling and the sprinklers are installed with the pipe above and the heads below the drop ceiling. The sprinkler installer is hanging the pipe where it touches duct, electrical conduit and is hung from the trusses. My question is, is this non-compliant?

A: It depends on the size of pipe and where it is supported from. Generally speaking, sprinkler piping may only be connected to the building structure, such as beams, trusses and decks. But there are some exceptions. Section 9.2.1.1 of NFPA 13-2010 says sprinkler piping must be supported independently of the ceiling sheathing, but they do allow sprinkler pipe up to 1½-inch or smaller diameter pipe to be supported from ceilings of hollow tile or metal lath and plaster. But this excludes acoustical tile ceilings, and gypsum board ceilings. Section 9.2.1.3.1 says unless the requirements of 9.2.1.3.3 apply (which allows special hangers for flexible piping), sprinkler piping shall be substantially supported from the building structure, which must support the added load of the waterfilled pipe plus a minimum of 250 lb. applied at the point of hanging. Section 9.2.1.3.3 discusses Flexible Sprinkler Hose Fittings, and says listed flexible sprinkler hose fittings and their anchoring components intended for use in installations connecting the sprinkler system piping to sprinklers shall be installed in accordance with the requirements of the listing, including any installation instructions. This allows the special hangers for flexible piping to connect to the grid of acoustical tile ceilings. Section 9.2.1.4 on Metal Decks, says branch line hangers attached to metal deck shall be permitted only for the support of pipe 1 inch or smaller in size, by drilling or punching the vertical portion of the metal deck and using through bolts. Section 9.2.1.5 says where sprinkler piping is installed below ductwork, the piping shall be supported from the building structure or from the ductwork supports, provided such supports are capable of handling both the load of the ductwork and the load of the pipe, the water inside the pipe and an additional 250 lbs. Remember, section 9.1.1.7 says sprinkler piping or hangers shall not be used to support non-system components. Take a look at the sprinkler system design drawings… often the sprinkler designer will specify where sprinkler piping is required to be supported. See if the installing contractor is following what has already been designed and approved. But, NFPA 13-2010, chapter 9 on hangers should take precedent over whatever the designer specifies.

Perforated Ceiling Tiles

Q: My facility is installing perforated ceiling tiles because it looks “modern” and does not look like the old healthcare setting. With the perforation in the ceiling tiles, does this mean I have to install sprinklers and fire alarm smoke detectors above and below the ceiling since the dropped ceiling is no longer a smoke-resistant barrier? I believe I have to also take the smoke compartment barrier walls to the deck… is that correct?

A: First of all, do you need smoke detectors in the area where the new ceiling tiles are being installed? If yes, then we need to address this issue, but the NFPA codes and standards do not require that many smoke detectors in a hospital. Unless you are employing Specialized Protective Measure locks (see section 19.2.2.2.5.2 of the 2012 Life Safety Code), or have specific requirements from a state or local authority that exceed what NFPA requires, smoke detectors are only mandatory in the following locations of a hospital:

  • In areas open to the corridor that are not directly supervised by a person (see section 19.3.6.1 of the 2012 LSC)
  • Near doors that are held open by devices that release on a fire alarm activation (see section 17.7.5.6.5.1 of NFPA 72-2010)
  • In elevator lobbies and elevator equipment rooms (see section 9.4.3.2 of the 2012 LSC)
  • In rooms where fire alarm panels (including NAC panels and off-premises monitoring transmission equipment) are located without direct supervision by a person (see section 9.6.1.8.1 of the 2012 LSC)

You may want to revisit why the smoke detectors are there in the first place. Check with your state and local authorities to see if they have requirements for smoke detectors to be there.

But assuming you do want to maintain the smoke detection level in this area where the new ceiling tiles are located, NFPA 72-2010 does address this issue. Let’s look at section 17.5.3.1.3 which discusses the requirements for an open grid ceiling. It says smoke detectors are not required below an open grid ceiling if the openings in the ceiling are ¼-inch or larger in the least dimension, and the openings constitute at least 70% of the surface area of the ceiling. So, what this means, smoke detectors are not required above the ceiling if the openings are less than ¼-inch and the accumulative area of the openings is 30% of the total surface area of the ceiling. But this section only applies if smoke detectors are required in the general area where these new ceiling tiles are being installed. But keep in mind, if you install smoke detectors where they are not required, they still must be installed in compliance with NFPA 72-2010.

Here are the requirements found in NFPA 13-2010, at section 8.15.13 for an approved open-grid ceiling. Open-grid ceiling must be installed below the sprinklers where all of the following apply:

  1. The openings of the open-grid ceiling must be at least ¼ inch or larger in the least dimension.
  2. The thickness or the depth of the material does not exceed the least dimension of the opening.
  3. The openings must constitute 70 percent of the area of the ceiling material.

If your ceiling tile openings are less than ¼-inch and the openings in the ceiling tile equal less than 70% of the ceiling area, then I conclude sprinklers would not be required above the ceiling.

There is one issue you need to be aware of… Most surveyors will cite you for having gaps in ceiling tiles greater than 1/8-inch as that would allow heat and smoke to filter up through the ceiling and would cause the sprinklers or smoke detectors to delay activation. Make sure these ceiling tiles do not have openings greater than 1/8-inch.

Smoke compartment barrier walls always have to extend from the floor to the deck above regardless whether or not the ceiling tiles have openings in them.

Fully Sprinkler Existing Hospitals

Q: Is there presently a date in place in which existing Healthcare Occupancies (remaining portions or in their entirety) must be fully sprinklered?

A: Yes and no.

All existing high-rise hospitals must be fully protected with sprinklers by July 5, 2028. This was decided by CMS in their Final Rule to adopt the 2012 Life Safety Code.

For existing hospitals that are not high-rise (i.e. do not have an occupied floor higher than 75 feet above the lowest level used by a fire department) there is no requirement to become fully sprinklered unless their construction type requires it or there is renovation.

Cleaning Sprinkler Heads

Q: How would I go about cleaning the dust off the sprinkler heads?

A: Use a portable vacuum cleaner. If the dirty heads are located in the kitchen, then you will need warm soapy water and a toothbrush. But you may want to leave that to a sprinkler contractor to do.

Non-Sprinklered Elevator Control Room

Q: In a physician’s clinic that is claimed to be fully protected with sprinklers, the building elevator control room is not sprinklered. Must I install or can I leave it that way?

A: A Business Occupancy building that is fully protected with sprinklers provides you with the ability to meet certain options in the LSC that allows you to take advantage of certain features, such as:

  • Delayed egress locks would be permitted
  • Less restrictions on egress capacity factors
  • Exits permitted to discharge through the interior of the building
  • Less restrictions on hazardous areas
  • Less restrictions on interior finishes
  • Increased travel distances

According to NFPA 13-2010, the standard for sprinkler installation, there are very few exceptions to not installing sprinklers, and allow the building to still be considered fully sprinklered:

  • 2-hour fire-rated barriers around an electrical room
  • Clean agent suppression system installations

However, the 2012 Life Safety Code does have an exception specific to elevator machine rooms. Section 7.14.4.2 says sprinklers shall not be installed in elevator machine rooms serving occupant evacuation elevators, and such prohibition shall not cause an otherwise fully sprinklered building to be classified as non-sprinklered. This is one situation where the Life Safety Code trumps NFPA 13 on the installation of sprinklers.

The 2012 Life Safety Code Handbook continues to provide insight on this prohibition:

The presence of sprinklers in the elevator machine room would necessitate the installation of a shunt trip for automatically disconnecting the main line power for compliance with ASME A17.1 Safety Code for Elevators and Escalators, as it is unsafe to operate elevators while sprinkler water is being discharged in the elevator machine room. The presence of a shunt trip conflicts with the needs of an occupant evacuation elevator, as it disconnects the power without ensuring that the elevator is first returned to a safe floor so as to prevent trapping occupants.

So, no… you should not install sprinklers in the elevator machine rooms.

Sprinkler System Exceptions

Q: Are there any exceptions in NFPA 13 for smoke detectors in lieu of sprinklers in areas such as radiology rooms or other high tech equipment rooms and still be considered “fully sprinklered”?

A: No. There is an exception in Section 8.15.10.3 of NFPA 13-2010 that allows electrical rooms not be sprinklered, and the building can still be considered fully sprinklered, provided the room is dedicated to electrical equipment only; only dry-type electrical equipment is used; equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations; and no combustible storage is permitted in the room.

And, you can install clean agent suppression systems in lieu of wet sprinklers and the building is still considered fully sprinklered, but there are no exceptions allowing smoke detectors in lieu of sprinklers in any type of room, and still consider the building “fully sprinklered”.

Sprinkler Inventory

Q: We are a life safety service company that provides consultation services for multiple hospitals. We had a hospital go through a survey recently, and the surveyor wrote them up for not having an inventory of sprinkler heads. Would you know where we could find this requirement for this inventory?

A: The surveyor may be looking at NFPA 13-2010, section 6.2.9.7, which does require the facility to have a spare sprinkler list, which is based on the different types of sprinklers in your facility and the quantity of those sprinklers. While this is not the same as saying an inventory of the sprinkler heads is required, you do need to know the types and quantities of sprinklers in your facility.

Or the surveyor may be looking at NFPA 25-2011 section 5.2.1, which requires an annual inspection of all the sprinkler heads. Usually, the hospital will contract this out to a sprinkler contractor and often the report simply says “All sprinkler heads inspected”, or something like that. The problem is, how does the hospital know that the contractor actually inspected every sprinkler head in the hospital? Did the contractor enter every room, every closet, every office, every OR, every equipment room, etc. in the facility? Without a detailed inventory or documentation (such as drawings of sprinklered areas) showing the heads were inspected in the respective areas, what assurance does the hospital (and the surveyor) have that every head was inspected?

But to be sure, there is no direct NFPA standard that says “Thou shalt inventory every sprinkler”, but it is well within the right of the authorities to request documentation that assures how the facility documented the spare sprinkler list and that the contractor inspected every head.

Sprinkler Obstructions

Q: My question is in regard to NFPA 13 sprinkler obstruction compliance…We want to install some surveillance monitors in our security office along a wall. How much vertical clear space is required between the monitors to the ceiling, if the monitors will be 30 inches away, horizontally from the sprinkler head?

A: Those monitors may extend vertically up to the ceiling as long as they are not directly underneath a sprinkler head, and they are attached to the wall. You said they were 30 inches away horizontally from the sprinklers, so you should be okay.

The Annex section A.8.6.6 of NFPA 13-2010 says the following:

“The 18 in. (457 mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 8.6.6, 8.7.6, 8.8.6, and Section 8.9. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (457 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (457 mm) below the ceiling sprinkler deflectors.”

While the monitor may not be shelves, the concept is the same.

Strange Observations – Sprinkler Pipe Supported From Ductwork

Continuing in a series of strange things that I have seen while consulting at hospitals…

This is another picture of sprinkler pipe supported from HVAC ductwork, similar to last week’s Strange Observations.

I include it here to emphasize that sprinkler pipe cannot be supported from anything except the building structure itself.

I suspect I see this problem in 75% of the hospital where I consult… but then, I’m looking for it.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.