Fire Barriers in Ambulatory Healthcare Occupancies – Part 1

Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised as to whether or not this Endo Unit needs a firewall separation. Where does the Life Safety Code discuss the requirements for Endo Units? What options do we have if we do not have the requisite fire barriers?

A: You won’t find the phrase Ambulatory Endoscopy Unit (or Endo unit) in the Life Safety Code, because the code deals with different occupancy designations, not different uses within those specific occupancies. You didn’t say, but I’m guessing the Endo Unit is classified as an ambulatory healthcare occupancy, as I suspect the patient is sedated and incapable of self-preservation. Another assumption is made that this unit is an outpatient unit, thereby supporting the thought it is an ambulatory healthcare occupancy. It appears you have an outpatient endoscopy unit that serves 4 or more patients that are incapable of self-preservation. That makes it an ambulatory healthcare occupancy designation. Ambulatory healthcare occupancies are required to be subdivided into at least 2 separate smoke compartments with a 1-hour fire rated barrier. The 1-hour fire rated barrier must extend from the floor to the floor or roof slab above, and openings (i.e. doors) must be at least 1¾ inch thick, solid-bonded wood core and be self-closing. Exceptions to the subdivision into two smoke compartments are if the ambulatory healthcare occupancy is less than 5,000 square feet and fully protected with smoke detectors; or if the ambulatory healthcare occupancy is less than 10,000 square feet and protected throughout by automatic sprinklers. Ambulatory healthcare occupancies must be separated from other occupancies (i.e. business occupancies) by a 1-hour fire rated barrier that extends from the floor to the floor or roof slab above. Doors in this barrier must be ¾ hour fire rated, self-closing, and positive latching. There are other fire barriers that could be part of the Endo Unit, such as fire barriers separating hazardous areas from occupied areas, and barriers separating exit enclosures from occupied areas.

Ceramic Tiled Walls

Q: We have an old shower room that our administration wants to use for a maintenance workshop. In this room they will be storing paint and supplies. The walls and floors are lined with ceramic tiles. I read where ceramic tile has a fire-resistant rating. Would these ceramic tiled walls and floor comply with the requirement to have a fire-rated room for the maintenance workshop?

A: No. The Life Safety Code requires a new maintenance shop that stores paint to have 1-hour fire-rated walls, with doors that are ¾-hour fire rated, self-closing and positively latching. While ceramic tile may have some sort of fire resistance value, the actual walls and floors must comply with an approved assembly that is listed by an independent testing laboratory. The fact that the walls and floors are covered with ceramic tile does not meet this requirement. If you are unsure if your walls meet the 1-hour fire rating, I suggest you consult with a design professional to make sure.

Fire Protection of Equipment Rooms

Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We have a disagreement as to what is required and your answer decides who is correct.

A: According to NFPA 110 (1999), section 5-2.1, generator rooms are required to have 2-hour fire rated barriers that protects the room from fire outside the room. Any 2-hour fire rated barrier is required to have 90-minute fire rated doors and frame and if there are any HVAC duct penetrations through the 2-hour barrier, then the HVAC duct opening needs to be protected in accordance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating System, which would require a 90-minute fire damper. A boiler room is considered a hazardous area, and according to the 2000 edition of the LSC, sections 18/, the hazardous area is required to be protected with 1-hour fire rated barriers if it is considered new construction, or 1-hour barriers if it is considered existing and is not protected with sprinklers. Existing boiler rooms that are protected with sprinklers only require smoke resistant walls. All door openings in a 1-hour barrier are required to be ¾ hour fire rated, with fire rated frames. However, unlike the 2-hour barrier, a 1-hour fire rated barrier for a hazardous area is not required to have any fire dampers in a HVAC duct penetration, unless the HVAC penetration is not fully ducted. Electrical rooms typically are not required by the LSC to have fire rated barriers (walls), however NFPA 13 (1999 edition) Standard for the Installation of Sprinkler Systems, section 5-13.11 does permit an electrical room to be protected with 2-hour fire rated barriers in lieu of being protected with sprinklers. Therefore if the room does have fire rated barriers for any reason (including local or state building codes) then it would need fire dampers in the HVAC duct penetration if it is 2-hour fire rated or greater. Chiller rooms typically do not require fire rated barriers, unless the chillers are fuel-fired, then they would require the same protection as the boilers. As always, please check with your local and state authorities to determine if there are other regulations that may affect this situation.

Good Luck!

ILSM on Fire Door Replacement

Q: If renovation requires replacement of fire doors in multiple areas of the hospital, and must be completed in a short period of time, what would be appropriate interim life safety measures? This would cover multiple areas of the hospital.

A: Appropriate Interim Life Safety Measures (ILSM) for replacing multiple fire doors in a hospital all at the same time would be determined by hospital’s ILSM policy. According to Joint Commission’s standard LS.02.01.01, EP 3, the ILSM policy must include criteria for evaluating when and to what extent the hospital follows special measures to compensate for life safety risks. What this means is the hospital gets to decide what ILSM measures to implement for which life safety impairments, within reason. But, to directly answer your question, I would think the following measures should be considered for implementation:

  • Staff education:  Issue a memo to all departments that are affected by the fire door replacement, notifying them of alternative routes for exiting.
  • Temporary construction partitions: Fire retardant plastic sheeting needs to be installed to contain dust and dirt during the demolition and construction phase of the fire door replacement project.
  • Issue additional fire extinguishers: Place extra fire extinguishers in the project area and provide instructions to the construction workers on how to operate them
  • Daily surveillance: Daily surveillance to ensure the fire door project area is clean and free from debris should be performed, as long as the project is active.
  • Post signage: If the project to replace the fire doors blocks access through the egress corridor in that area, then signage should be posted indicating the nearest alternative exit.
  • Fire watch: If any portion of the fire alarm system or the sprinkler system is impaired for 4 or more hours in a 24 hour period due to the fire door replacement project, notification of the local fire department is required and a fire watch must be performed

Enclosures for Emergency Generators

Q: Do emergency power generators have to be located in a room by themselves? We have a generator that is located in a mechanical room which is shared with an air-handler, condensate pumps and other equipment. This generator was installed in the 1970’s, but a consultant told us we had to relocate the generator to a 2-hour room where it can be located by itself.

A: NFPA 110 (1999 edition), section 5-2.1 says the generator must be installed in a separate room with a 2-hour fire rating, and no other equipment is permitted in the room. However, section 1-3 of the same standard says NFPA 110 only applies to new installations and existing systems are not required to conform to the standards, unless the authority having jurisdiction (AHJ) determines that nonconformity presents a distinct hazard to life. If the generator has been installed since the 1970’s and no AHJ has cited you for nonconformity, then I suggest it is safe to assume the AHJs that have inspected your facility do not have a problem with the arrangement. If an AHJ attempts to cite this situation for non-compliance with NFPA 110 (1999 edition) section 5-2.1, then I would make the case that it is not required to since this room was constructed long before NFPA 110 was in existence. NFPA 110 was first adopted in 1984 by NFPA, so it was not part of the Life Safety Code until probably the 1985 edition.  Therefore, it may be assumed it met the standards that were in existence in the 1970’s when the building was constructed.

Automatic Door Operator

Q: We are in the process of installing a door in a 2 hour fire barrier with an automatic door operator and positive latching. The door operator will be activated by two push plates mounted on the wall. In the event of a fire alarm, are we required to drop power to the door operator?

A: To be sure, fire-rated doors with automatic operators must close and latch during the activation of the fire alarm system, according to NFPA 80 (1999 edition), section 2-1.4.2. So, to answer your question: Yes, the power to the automatic operator on the fire-door you proposed would have to be interrupted during a fire alarm. The door must still be permitted to operate manually however, but the power to the automatic operator must be interrupted.

Existing Fire Rated Doors

Q: Do existing fire rated doors (in a 2-hour fire rated barrier) have to have a vision panel (window) in the door?

A: No, I do not believe that they are required to have vision panels, although they are permitted, as long as they are factory installed. Section of the 2000 edition of the Life Safety Code requires door assemblies in fire-rated barriers to comply with NFPA 80 Standard for Fire Doors and Fire Windows (1999 edition). Section 1-7 in NFPA 80 discusses glazing materials in fire doors, which is another name for vision panels, or windows. The standard discusses the requirements that must be followed when glazing materials are installed in fire rated doors, but it does not specify that glazing materials is required in existing fire rated doors. For fire rated door assemblies in new horizontal exits, vision panels are required, according to section of the Life Safety Code.

Fire Rated Walls and Barriers

Q: Are fire rated walls the same thing as fire rated barrier? And are smoke compartment barriers actually fire rated walls?

A: As it has been explained to me, a fire rated wall is used to subdivide a building into separate areas and they extend from an outside wall to another outside wall, and from the floor of the lowest level up through the roof of the highest level. A fire rated wall is structurally self-sufficient and acts as a block in the event a fire develops on one side, to prevent the fire from spreading to the other side. Fire rated walls are specified by building codes, and are not addressed by the Life Safety Code for healthcare occupancies. On the other hand, a fire rated barrier is not a fire rated wall, and are used extensively in healthcare occupancies. A fire rated barrier extends from the floor to the deck above. Examples of a fire rated barrier would be the walls surrounding a hazardous room; a vertical shaft (such as a stairwell or elevator shaft); and a separation between different occupancies or construction types. All opening in fire rated walls and fire rated barriers (such as doors, dampers, access panels, etc.) must be fire rated and equipped with fire rated frames and hardware. To be sure, smoke compartment barriers are not fire rated barriers; however they are similar. The barrier itself is constructed with fire rated materials however the doors in the smoke compartment barriers are not required to be fire rated, nor are they required to have positive latching hardware. They only have to self-close. Smoke compartment barriers are required to extend from the floor to the deck above. Another barrier that you may need to know about are smoke resistant barriers, which have no fire rating, but are required to extend from the floor to the deck above, and resist the passage of smoke. Corridor walls in a non-sprinklered smoke compartment are required to be smoke resistant barriers.

Construction Type Barriers vs. Occupancy Separation Barriers

Q: I read with interest the article Understanding the Importance of Construction Types in the February, 2011 issue of HLSC. The article said a 2-hour fire resistance horizontal barrier is not allowed to separate different construction types, only vertical barriers. Isn’t a 2-hour rated floor assembly permitted to separate different construction types? Isn’t a 2-hour barrier sufficient to distinguish a barrier between different buildings?

A: You may be confusing different purposes for a 2-hour fire resistance rated barrier. Separating different construction types requires a 2-hour vertical barrier. Separating different occupancies that involves healthcare requires a 2-hour vertical and/or horizontal barrier. Section 8.2.1 of the 2000 edition of the Life Safety Code® (LSC) only permits vertical 2-hour fire resistance rated separations between different construction types, and does not permit horizontal barriers. The reason behind this requirement is very logical. The requirement for the fire resistance rating of construction types is based on the estimated time it takes to evacuate the building in the event of a fire. Most multi-story hospitals are required to be at least Type II (222) construction which allows for the extra time it would take to evacuate non-ambulatory patients from the building. If a lower floor was permitted to be less that Type II (222) construction, even if it were separated by a 2-hour fire rated floor assembly, a fire on the lower floor which has less fire resistance rating on its structural support members may cause the building to collapse before all of the patients are evacuated. Section does not restrict the 2-hour barrier between different occupancies to either vertical or horizontal, therefore they are both permitted.