Clinical Needs Locks

Q: For clinical needs locks, can occupants pass through four locked doors (patient room door, a cross-corridor door, another cross-corridor door, and a door at exit discharge) in a required single path of egress? (All options have 4 locked doors in the path.)

A: The 2012 Life Safety Code does not address any restrictions on how many doors in the path of egress may be equipped with Clinical Needs locks. Therefore, if the LSC does not prohibit it, then it is permitted.

However, not all AHJs permit it. For example; I am told that the IBC prohibits more than one Clinical Need lock in the path of egress (or, at least they used to). When I worked at the hospital, I tried to get the state to allow two locked doors in the path of egress from the Psychiatric unit but they would not allow it.

But in my travels, I have seen multiple doors in the path of egress equipped with Clinical Needs locks where permitted in various states around the country. The most common use of multiple Clinical Needs locks create a ‘Sally Port’ or ‘airlock’ that allows one locked door to open but the other locked door must be closed. This is an added security to prevent anyone from eloping.

So, the LSC does not prohibit it, but the IBC and some AHJs do.

Lower Bottom Rod Latching

Q: My question is regarding a 2-hour fire-rated wall that is separating our physical therapy department and the main hospital. In between the two is a long glass hallway with a dual egress 90-minute fire-rated door. The doors are top latching. I have had an environment of care consultant say that the door has to be top and bottom latching. Their reasoning is because it separates two occupancies. But both occupancies are owned by the hospital, and are not separate entities. Does the dual egress door have to be top and bottom latching?

A: Maybe yes and maybe no… The requirement for a lower bottom rod is dependent on the door assembly manufacturer’s UL listing when they had the door tested. It is not a NFPA standard that all doors have to have a lower bottom rod, but rather it is driven by the manufacturer’s hardware listing from UL.

I have not seen the door assembly but your consultant has. If there is evidence that the lower bottom rod on the fire-rated door assembly was originally installed and now it has been removed, then yes you need to re-install it and have a top and bottom latching connection. This is not uncommon after a few years when the lower bottom rod becomes damaged, and the hospital maintenance just removes it since it latches at the top. If that is the situation for you, then that would be a non-compliant situation.

In some cases, the door manufacturer provides a ‘Fire Pin’ in lieu of the lower bottom rod, which is spring-activated to shoot a pin horizontally from one leaf to the other to hold the door closed during a fire. These ‘Fire Pins’ do not operate until the temperature at the floor reaches 450°F or thereabouts, so there is no chance of the pin activating prior to anyone wanting to use the doors.

Then I’ve been told there are a few door manufacturer’s that have passed the UL testing whereby they are only required to have a latching device at the top of the door, and not at the bottom of the door. I’ve never seen one, but I’ve been told they are out there.

I suggest you contact the distributer of the door in question and ask them what hardware is required in order to maintain the fire-rating from UL. Then maintain that documentation for future reference during a survey.

Fire Pins

Q: I had a company put in the fire plugs on the doors to replace the lower bottom rods. Was this okay? They say that the plugs have a thermal-pin that will secure the door in case there was a fire.

A: You must be referring to fire pins… I cannot say if this is okay or not. That is up to the manufacturer of the fire doors. You are not allowed to modify a fire-rated door assembly other than what the manufacturer permits. If you haven’t already done so, contact the manufacturer of the door and ask them if fire pins are permitted to be installed in their door in lieu of the lower bottom rod after the door is installed.

The manufacturer achieves a listing from an independent testing laboratory for the fire-rating of their door assembly. If you modify that door assembly beyond what was tested and listed by the testing laboratory, then you have violated the listing of the door and the entire door assembly would need to be replaced.

Delayed Egress Locks

Q: Lately, due to many different construction projects within this hospital, contractors install crash bars (aka panic bars) on doors that have locks for security reasons. The doors do lead to alternate evacuation exits/stairs. The crash bars release the locks in 15 seconds and I have been told that signs notifying people of this is required on the doors. Where is the code for this requirement? One location is an entrance directly into an outpatient care service directly off the public elevator lobby. At two newer locations on another floor, employees are to use their ID badge for access but in one location the sensor is not readily seen. In this location employees frequently open the door via the crash bar setting off the alarm requiring someone to go there to reset the alarm. The message contractors are putting on the doors read: PUSH UNTIL ALARM SOUNDS / DOOR CAN BE OPENED IN 15 SECONDS. The message gives people permission as well as instruction of how to enter a secured area. Where is this code requiring the sign and does it specify the message?

A: Yes… The answer to your question is: Section of the 2012 Life Safety Code.

What you have on these doors are called “Delayed Egress Locks”, and the sign that reads “PUSH UNTIL ALARM SOUNDS – DOOR CAN BE OPENED IN 15 SECONDS” is a requirement. If you don’t have these signs, you can be cited by an inspector or surveyor.

Also, as an FYI… you are not allowed to use delayed egress locks on doors in the required path of egress unless the facility is fully smoke detected or fully sprinklered. So, check with your staff to determine if your building is fully sprinklered. In all my 40+  years in this business, I have never seen a fully smoke-detected hospital.

Keep in mind, delayed egress locks are not designed to secure an area. They are designed to allow access through the door on a delayed basis. If the door is located in the required path of egress, then you cannot secure the door, unless it meets one of the exceptions provided in section

Magnetic Locks

Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director?

A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (i.e. relays, control modules) be tested once per year. Since the magnetic locks in access-control and delayed egress locks are connected to the fire alarm system via an interface relay, then the magnetic lock needs to be tested once per year to ensure it disconnects during a fire alarm signal. This test is required to be conducted by someone who is certified in accordance with NFPA 72.

If you are CMS certified or accredited by any of the major accreditation organizations then you would be expected to comply with the manufacturer’s recommendations on preventive maintenance. Most manufacturers of magnetic locks requires periodic maintenance to ensure they are functioning correctly.


Q: According to the 2012 Life Safety Code, section, the distance between a handrail and adjoining wall should be 2¼-inches. Does this apply to just spaces in which NFPA requires handrails such as stair and ramps, or does it apply to corridors where a handrail is not specifically required by NFPA? If so, then in areas where NFPA does not require a handrail, but one is installed such as in a corridor, can the distance between the handrail and the wall just have to comply with ADA and the building code, which is 1½-inches?

A: Section of the 2012 LSC does require new installation of handrails on stairs and ramps to be at least 2¼ inches from the wall. Since section is a sub-section of 7.2.2 “Stairs”, this 2¼ inch requirement is limited to just stairs and ramps. It does not apply to handrails on corridors.

I do not see any restrictions on clearance between a handrail and the wall in corridors, other than the CMS limitation of 4-inches maximum projection into the corridor.

Staff Sleep Rooms

Q: In regards to audio/visual strobes in staff sleeping rooms, is it required for them to hear the fire alarm system?

A: According to section of the 2012 Life Safety Code, single-station smoke alarms are required to be installed in sleeping rooms for lodging or rooming house occupancies. A staff sleeping room in a hospital would have to qualify for the requirements of a lodging or rooming house occupancy, so a single station smoke alarm is required.

A single station smoke alarm has a built-in occupant notification device. But section of the 2012 Life Safety Code says fire alarm system smoke detectors that comply with NFPA 72 and are arranged to function in the same manner as a single-station smoke alarm shall be permitted in lieu of smoke alarms. Even if you install a fire alarm system smoke detector in the staff sleeping room, section would imply that some sort of occupant notification device is still required to awaken the staff member sleeping in that room.

But section 18.4.4 of the NFPA 72-2010, allows for the Private Mode installation for fire alarm system occupant notification devices, and hospitals typically are designed to this requirement. Section requires the occupant notification device to have an audible sound level 10 dB above the average ambient sound level to be compliant, and in many cases, an occupant notification device located in the corridor outside of the staff sleeping room can achieve this requirement.

If you measure the dB level inside the staff sleeping room of the corridor-mounted fire alarm system occupant notification device, and it is 10 dB above the average ambient sound level in the staff sleeping room, then you should be good. But have those sound readings available to show the surveyor, as they will want to see some proof of compliance.

Fire Extinguishers

Q: At our hospital there is some question about which type of portable fire extinguisher should be installed in our operating rooms. We can’t find an actual requirement for this and would appreciate your opinion.

A: I don’t think you will find anything in the NFPA codes and standards that recommends a type of fire extinguisher to be used in an operating room. To be sure, section of the 2012 LSC says portable fire extinguishers must be selected, installed, inspected, and maintained in accordance with NFPA 10.

Section 5.1 of NFPA 10-2010 says the selection of fire extinguishers for a given situation shall be determined by the following factors:

(1) Type of fire most likely to occur

(2) Size of fire most likely to occur

(3) Hazards in the area where the fire is most likely to occur

(4) Energized electrical equipment in the vicinity of the fire

(5) Ambient temperature conditions

So, what types of fires are likely to occur in an operating room? I would say Type A fires (fires involving combustibles like paper, plastic, cardboard, linen); and Type B fires (fires involving combustible and flammable liquids, like skin prep alcohol); and Type C fires (fires started by electrical means). I don’t believe Class D fires (combustible metals) and Class K fires (cooking oils) are very likely in an operating room. 🙂

So, you need portable fire extinguishers that will cover ABC fires, but the most common ABC extinguisher is a dry powder and is not suitable to be used in an operating room. So, you could use a CO2 type extinguisher which could handle BC fires, as the CO2 is a clean agent that would not do any residual harm to the patient. But what to do about Class A fires? Most surgical procedures have sterile water in a basin in the sterile field of the surgery. You can teach the staff to use the sterile water on any Class A fire involving the patient or nearby.

Keep in mind, there is no requirement that you have to have portable fire extinguishers in the operating room. All you need is to meet the maximum travel distance to get to a fire extinguisher. You could place a Class BC extinguisher out in the corridor outside the operating room, which would be fine as long as you do not exceed the travel distance to get to a Class B extinguisher, which is 35 feet for a 5-lb. unit and 50 feet for a 10-lb. unit.

Separation Between Hospital and Parking Structure

Q: We have a three-story parking structure attached to a hospital. The top floor of the parking structure is not covered and is open to the atmosphere. Is the exterior wall of the hospital adjacent to the top floor of the parking structure required to be fire-rated? Our original drawings show the wall as not rated.

A: Yes… I would say so. According to section of the 2012 LSC, a parking garage would be considered a Storage Occupancy, and since this is contiguous to the hospital (which is a healthcare occupancy) section (2) would require that you need a 2-hour fire-rated barrier separating the healthcare occupancy from the storage occupancy.

Technically speaking, the entire parking garage is open to the atmosphere, so the only difference between the top deck of the parking garage and the lower decks is there is no roof on the top deck. The top deck is still a storage occupancy just like the lower decks. The LSC does not allow any exceptions to not provide a 2-hour fire rated barrier between the healthcare occupancy and any other occupancy just because it does not have a roof.

Strange Observations – That’s a Huge Step

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

The maximum rise in a existing construction step is 8-inches. The step in the picture to get into and out of this electrical room is about 20-inches.

There is nothing in the Life Safety Code that excludes mechanical rooms, or electrical rooms from having to comply with the requirements for a maximum rise in the step.

In this situation, it was going to be difficult to install a set of steps because this opening to the electrical room is directly off of the drive to the receiving dock.