Doors to Operating Rooms

By Brad Keyes…

Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that opens 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: Does the Life Safety drawings identify the sterile core area and the operating room together as 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 the door could be fine without a latching door between the OR and the sterile core area, because it is all one suite. 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.

There is another issue here… Most sterile core areas that I have seen qualify as an hazardous area, due to the many combustible items stored in the room. If the walls surrounding the sterile core area are 1-hour fire-rated, then the door itself would have to be 3/4-hour fire-rated (see of the 2012 LSC), and it would have to be self-closing and positive latching. If the walls surrounding the sterile core area are smoke partitions and the sterile core area is protected with sprinklers, then the door is not required to be fire-rated, but it must be self-closing (see and positive latching (see, which references which references

Based on the information you provided, it is probable that the door between the OR and the sterile core area would have to positively latch.

Gift Shops

Q: Are gift shops stilled classified as hazardous areas if they have quantities of combustibles? I do not see the standard for gift shops to be classified as hazardous areas in the 2012 addition.

A: Nope. The 2012 edition dropped the requirement that gift shops have to be considered hazardous areas that was found in previous editions.

Since the combustible items that are in gift shops (i.e. greeting cards, clothes, stuffed animals, etc.) are on display rather than ‘in storage’ they are not required to comply with of the 2012 LSC for hazardous areas. However, the storage room for gift shops still must comply with for hazardous areas.


Hazardous Rooms

Q: When dividing hazardous areas (particularly storage rooms exceeding 100 square feet), if there are several rooms in one area, is the one-hour fire rating allowed to surround the perimeter of all the rooms or does each room require a separate fire-rating?

A: There is no Life Safety Code requirement that would prohibit you from ‘grouping’ your multiple hazardous rooms together, into one large hazardous room, even though the multiple rooms are separated by non-rated barriers. So, yes, you can have the 1-hour fire rated barrier go around the outer perimeter of all the rooms and everything inside the 1-hour fire rated barrier would be considered a hazardous area.

Existing Hazardous Rooms vs. New Construction

Q: Our original hospital was constructed in 1968, then we had an addition in 1992 and our newest addition completed in 2013. Do the hazardous rooms in our buildings that are all fully sprinklered have to be maintained as 1-hour fire-rated walls with 3/4-hour fire-rated doors, or can we maintained them to just resist the passage of smoke based on the “existing” chapter? I was told that anything constructed before the date the Life Safety Code was adopted is now considered existing conditions.

A: To answer your question, the new construction healthcare occupancy chapter 18 applies to all buildings designed, approved and constructed after July 5, 2016, which is the date that CMS adopted the 2012 life Safety Code. That means all conditions designed, approved and/or constructed on or before July 5, 2016 would comply (as a minimum) to the existing healthcare occupancy chapter 19.

However, there are other conditions that you need to be aware of. According to section 4.5.8 of the 2012 Life Safety Code, whenever a feature of life safety is required by the LSC, it must be maintained as such, unless the LSC changes and the feature is no longer required. This means, if at the time the hazardous room was constructed the walls needed to be 1-hour fire rated and the door ¾-hour fire rated and the room be sprinklered, then you must maintain it that way, even though the room may now qualify as existing conditions and the walls and door only need to be smoke resistant.

So, for new construction hazardous rooms, section of the 2012 LSC requires the room to have 1-hour fire-rated protection which requires ¾-hour fire rated doors assemblies that self-close and positively latch. Section also requires the room to be protected with sprinklers. You would build your new construction (or renovated existing) hazardous rooms to 1-hour fire-rated walls (which must extend from the floor to the deck) and have the door assemblies meet ¾-hour fire rating.

Understand, the hazardous rooms constructed in the 1968 building would qualify for the existing conditions healthcare occupancy chapter 19 today because they were constructed before July 5, 2016, and at the time of their construction the Life Safety Code had not yet been adopted by any national governmental or accreditation organization. But the hazardous rooms constructed in the 1992 addition would have been required to be 1-hour fire rated with a ¾-hour fire rated door, and be protected with sprinklers, because that is what was required for new construction in 1992 for hazardous rooms. Therefore, since 4.5.8 says once it is built, you have to maintain it, it must remain 1-hour fire rated walls with ¾-hour fire rated doors and be fully sprinklered, even though it was built before July 5, 2016. Yes, it qualifies for existing conditions under the 2012 LSC, but since it was built to new construction requirements, that is what you must maintain, until the LSC changes.

Now, some hospitals have older hazardous rooms that for one reason or another, were not constructed to 1-hour fire-rated construction and protected with sprinklers, although they were supposed to. This was likely an oversight at the time of the construction by the AHJ or perhaps the hospital constructed the room without the AHJ’s knowledge or permission. When these old mistakes are caught, many authorities having jurisdiction (AHJs) are actually requiring the hospital to upgrade their old hazardous rooms to 1-hour fire-rated construction and meet new construction requirements. Their logic is, that is what was required back when the hazardous room was constructed, so it is being enforced now. Right or wrong, they have the authority to enforce that onto the hospital.

Clean Utility Rooms

Q: What is the guidance on clean utility rooms and door closers? Under 50 square feet no closer is required, but over 50 square feet a closer is required? Does the clean utility room being located inside a suite make any difference? The normal supplies in there could be considered combustible based on the NFPA definition.

A: You have the 50-square foot limit correct, but it does not matter if the clean utility room is located in a suite or not. It still must meet section 18/ for hazardous areas. If it is a new clean utility room, then it must be 1-hour fire-rated and be protected with sprinklers. However, the room may meet an exception found in section (2), regarding rehabilitation. A change in use of a space in an existing healthcare occupancy does not have to meet new construction requirements for hazardous areas, provided the space does not exceed 250 square feet and the entire building is protected with sprinklers. But the space does have to meet the requirements for hazardous areas for existing conditions, which is 1-hour fire rated construction, or if the room is fully protected with sprinklers, then the door just needs to be self-closing and smoke resistant.

Strange Observations – Part 11

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

This may be hard to see but there is an ‘Exit’ sign over the door at the end of this corridor. Storing combustibles in the corridor is creating a hazardous area and the path of egress may not enter a hazardous area to get to the exit.

This scene is probably familiar to many hospitals across the country, but you’ve got to take action to eliminate it before it becomes a tragedy.

Hazardous Area in Surgery

Q: Are clean cores for operating room suites considered hazardous thus required to be separated by a 1-hour fire-rated barriers? I have a client who was informed by their accreditation organization that their existing clean (sterile) core area needed to be upgraded to provide a 1-hour separation. The space is typically occupied and is larger than 100 square feet in a building fully protected by automatic sprinklers.

A: It depends… Is the hospital storing combustible supplies in the core area? If so, then the core area must meet the requirements for hazardous areas. Combustible supplies commonly found in core areas of Surgery are:

  • Paper-wrapped utensils that have been sterilized and waiting for use in surgery
  • Dressing, bandages, sutures, and medical equipment and supplies that are packaged in plastic, cardboard, chip-board, and paper
  • Other supplies that create a hazardous environment

The next issue is, does the hazardous area have to meet new construction requirements to be 1-hour fire rated and be fully sprinklered, or does the hazardous area qualify for the lesser requirements for existing conditions of being protected with 1-hour fire rated construction or smoke resistant construction and being fully sprinkelred? The answer to that question lies in which edition of the Life Safety Code was in effect at the time the core area was constructed or last renovated. If the core area was constructed or last renovated since the 1985 edition of the Life Safety Code was in effect, then yes, the core area is required to be protected with both 1-hour fire-rated construction and be fully sprinklered. (The 1985 edition was adopted by CMS, or the fore-runner of CMS, around January, 1988.) Subsequent editions of the Life Safety Code required new construction hazardous areas to be both 1-hour fire-rated protected and sprinklered. However, if the core area was constructed or last renovated before the 1985 edition of the Life Safety Code was in effect, then the core area is considered existing construction by today’s standards and qualifies for the existing conditions standards of being smoke resistant construction and fully sprinklered.

New vs. Existing Construction

Q: Our hospital facility was constructed under the new construction chapter 18 in 2000 Life Safety Code, but is now considered existing conditions under the 2012 Life Safety Code. We have a soiled linen room that is greater than 100 square feet, and is sprinkled, and the door needs to be replaced due to damage. Does the door still need to be a 45-minute fire-rated door assembly, now that the facility is in the existing category of chapter 19?

A: Yes, it does, because sections 4.5.8 and of the 2012 LSC says once a feature of life safety is required by the LSC, you must maintain that for the life of the building unless the new construction requirements change and no longer require it. Also, section says the existing feature of life safety cannot be removed where such feature is a requirement for new construction. So, you need to replace it with a properly rated fire door assembly for new construction. The reason there is an existing healthcare chapter that does not require a ¾ hour fire-rated door on a hazardous room, is it is for the older hospitals that built hazardous rooms when they were not required to be 1-hour fire rated. They are permitted to remain in use without having to meet the new construction requirements. But since your facility was constructed under the 2000 LSC that did require 1-hour fire rated hazardous rooms, you need to maintain that for the life of the building.

Hazardous Cart in Corridor

Q: I recently heard that a hospital was cited for leaving a construction cart unattended in the hall and the surveyor inventoried the entire cart and cited the hospital for each hazardous item present. Can they do this and is there a life safety code addressing this issue?

A: Yes they can do this, as they are an authority having jurisdiction. They get to interpret the Life Safety Code as they see fit. While this finding may seem to be “ticky-tacky” to you, the bottom line is the surveyor has the right to ensure your facility is safe for patients, staff and visitors. If there is an unattended cart containing sharp objects, toxic chemicals, flammable gases, etc., in the corridor where it is available to unauthorized individuals, then that really is a legitimate safety issue. You ask if this is a Life Safety Code violation, and I would say it can be considered a LSC violation, based on section of the 2012 edition. Also, section 19.3.2 discusses hazardous areas, and technically speaking, an unattended cart containing these “hazardous items” is considered in storage, and therefore would have to meet the requirements of 19.3.2. All-in-all, it really is a legitimate finding, and the hospital needs to take action to prevent it from happening again in the future.

Paint Storage

Q: Is it okay to store latex paint in a mechanical/air handler room? The mechanical room is located in the hospital and is in a 2 hour fire rated wall enclosure.

A: This is an issue that is addressed by the Life Safety Code, but is not always enforced the same way by authorities.

Section of the 2012 Life Safety Code specifically states “Paint shops” are hazardous areas. The interpretation by the AHJ would likely be that all paint needs to be stored in a hazardous room that meets the requirements of So, from that perspective, the cans of latex paint would have to be stored in a hazardous room.

Now, can your AHU mechanical room qualify as a hazardous room? I believe it can, provided there is no fuel-fired equipment in the room, and it meets the requirements for hazardous room found in section But not all AHJs actually interpret this section of the LSC in the same way. Some state and local AHJs do not like to see any storage in mechanical rooms, since the main purpose of the mechanical room is to house the air handling units. But since storage is at such a premium for hospitals, why not double up and allow storage in mechanical rooms provided it meets all of the code requirements?

As you may see, not all AHJs think this way, and you may encounter some resistance to this way of thinking.