Ambulatory Suites

Q: Am I allowed to have a suite inside an area designated as an Ambulatory Occupancy? And for clarification, do suite boundary walls need to be one-hour fire rated?

A: Yes… you are permitted to have a suite in an ambulatory health care occupancy. Look at section 20/21.2.4.3 which permits suites in AHCO, but any suite over 2,500 square feet must have two remotely located doors from the suite. No… Suite boundary walls are not necessarily required to be 1-hour fire-rated. They are required to be equal to the fire-resistive rating of the corridor walls. For new construction, corridor walls would be a minimum of 1-hour fire rated barriers, unless one of the following exists:

  • Where exits are available from an open floor area
  • Within a space occupied by a single tenant
  • Within buildings that are fully protected with automatic sprinklers

For existing construction, there are no requirements for corridor walls, so therefore there are no requirements for suite boundary walls.

Suite Doors

Q: Does the 2012 edition of the Life Safety Code permit existing suite doors that open into the corridor to be compliant if they do not latch shut? We have different interpretations of 19.2.5.7.1.2.

A: No. Corridor entrance doors to suites must latch. Section 19.3.6.3.5 requires all corridor doors to latch. CMS does not allow the exception for a device that holds the door closed with 5 lbs. of force.

Since a suite is nothing more than a large room with smaller rooms inside, the barrier that separates the suite from the corridor must meet the conditions for corridor walls, which means the door must latch. The provision in 19.2.5.7.1.2 (2) is written to allow existing suites to have smoke resistant walls when fire-rated barriers are required by the corridor walls.

Direct Visual Observation Required in Emergency Department

Q: If an Emergency Department is greater than 7500 square feet but less than 10,000 square feet and is deemed to have “sleeping accommodations”, do the requirements of direct visual observation per 19.2.5.7.2.1(D)(1)(a) apply since only “sleeping accommodations” are provided and not a full “patient sleeping room”?

A: According to CMS, the answer is yes. They consider an Emergency Department that provides observation beds to be sleeping accommodations and must comply with healthcare occupancy sleeping suite requirements, and all that is required. They also consider the patient as ‘inpatients’, which seems to be contrary to the what the rest of the world believes.

See if you can do one of the following:

  • Eliminate the ‘observation beds’
  • Relocate those ‘observation beds’ to a regular inpatient unit
  • Divide your ED up into multiple suites to get around the direct observation requirement for sleeping suites over 7500 square feet.

Suites in AHCO

Q: We recently had a surveyor tell us that suites are not allowed in ambulatory healthcare occupancies. Can you help explain this and any code references that support your opinion?

A: Well… that surveyor is mistaken. Suites are definitely permitted in ambulatory health care occupancies (AHCO). Sections 20/21.2.4.3 of the 2012 LSC specifically permit suites and says any site larger than 2500 square feet must have at least two exit access doors remotely located from each other.

The term ‘remotely located’ is defined by section 7.5.1.3.2 which says the two exits must be located at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the suite, measured in a straight line between the nearest edges of the exits. In a fully sprinklered building, section 7.5.1.3.3 says it is 1/3 the length of the maximum overall diagonal dimension of the suite.

There are no size limitations on suites in AHCO. And they are not prohibited in business occupancies either, even though there is no advantage to having them in business occupancies. I suggest you ask the surveyor (if he/she is still with you) to show you where in the LSC it prohibits suites in AHCO. I also suggest you ask your state and local authorities if they have any restrictions that would prohibit suites in AHCO.

Air Pressure Requirements for OR Suite

Q: I have a small 28 bed hospital with one OR suite. Within the OR suite are sterile rooms, a soiled room, and of course the Operating Room, etc. We are rebalancing the air flows for the entire floor which is all health care occupancy. I am aware that the rooms mentioned above, all have air pressure relationship requirements to adjacent areas per the Guidelines for Design & Construction of Hospitals and ASHRAE 170. However, some are questioning the need to have a positive air pressure relationship between the OR suite and other areas. That is, they measure the pressure from the OR suite door to other side which is the in-patient corridor. Is there any pressure relationship requirement in this location?

A: ASHRAE Standard 170: Ventilation of Health Care Facilities section 7.1.a.1 states that design of the ventilation system shall provide air movement that is generally from clean to less clean areas. Since surgery departments may or may not be suites, the ASHRAE 170 ventilation Table 7-1 in the FGI Guidelines does not address that. You are correct that the actual operating room has to have a positive air pressure relationship to its surrounding areas. But in addition,  sterile storage areas should have a positive pressure relationship to all adjacent areas except ORs and restricted areas within a surgery suite should have a positive pressure relationship to all adjacent areas except ORs and sterile storage areas.

Patient Room Doors in a Suite

Q: In a newly designated ICU suite, do the doors to the patient rooms have to be positive latching?

A: No… The doors to patient rooms that are located inside a suite are not required to positively latch. The reason for this; the requirement for a door to latch for a patient room is found in section 19.3.6.3.5 of the 2012 LSC when the door is a corridor door. A corridor door separates the corridor from a room or an area, such as a patient room. However, in a suite there are no corridors… what appears to be a corridor is actually a communicating space. Therefore, there is no requirement for doors to patient rooms to positively latch inside a suite. Actually, there is no requirement for doors inside a suite to patient rooms, which is quite common in Pre-Op, Post-Op, ER, and some ICUs.

Barriers Separating Suites

Q: We have two adjacent suites that are not separated by a smoke wall. My question is; does a door along that separation have to meet the requirements of a smoke door? The door does not open into a corridor, it is only separating the two suites. Also, should that suite separation barrier be a smoke wall all alone the separation?

A: There are requirements for the barrier that separates two adjacent suites, but the phrase you use “smoke wall” is not the correct description. According to section 19.2.5.7.1.2 of the 2012 Life Safety Code, the barrier that separates suites from other suites (and the barrier that separates suites from all other areas of the hospital), must be equal to the construction of the existing corridor walls as described in 19.3.6.2 through 19.3.6.5. This means, if your corridor walls are permitted to be non-rated smoke resistant and extend from the floor to the ceiling, then that means the barrier separating the two suites must be as well. However, if your corridor walls are required to be ½ hour fire rated and extend from the floor to the deck above, then that is also the requirement for the barrier separating the two suites. In both cases, the door between the two suites would have to resist the passage of smoke and be positive latching, but is not required to be fire-rated or self-closing. You use the phrase “smoke wall” which is ambiguous. That is not a NFPA term. According to NFPA, there are smoke partitions (i.e. corridor walls, non-rated hazardous room walls) and there are smoke barriers (i.e. barriers that separate smoke compartments), and there are different requirements for both.

Suite Entrance Doors

Q: A hospital has 2 different suites with double egress entry doors and the Joint Commission surveyor noted that these doors are supposed to have latching hardware because they are “corridor doors,” but in my experience, cross-corridor doors are not typically required to have latching hardware.  Can you weigh in on this?

A: I agree totally with the surveyor. According to the LSC, suites are nothing more than rooms; albeit a large room with smaller rooms inside. Therefore, corridor entrance doors to suites must positively latch because corridor doors are required to latch according to 18/19.3.6.3.5, 2012 LSC.

The thing that throws people off is what looks like a corridor inside a suite is not a corridor; it is a communicating space. The requirements of a corridor do not apply inside a suite. But the designers often make this space 8 feet wide and for all intent and purposes people think it is a corridor. Then, the designer places double egress doors as entrances to the suite (which is good when you’re pushing patients in an out on beds) and the doors look like cross-corridor doors. They’re not; they are corridor doors.

The hospital has to make those doors positively latch or they have to change the designation from a suite to a corridor, which is not advisable.

Suite Entrance Doors

Q: We have a double egress, cross-corridor door which will enter a suite under a renovation project. The suite wall is also an existing smoke barrier wall, separating smoke compartments. However, we do not want an exit route through the suite, as this would be a code violation. The new layout will not cause a dead-end corridor and the suite will house less than 50 people. Is it allowable to replace the double egress door with a pair of out swinging doors?

A: As long as the new doors are not cross-corridor doors, I believe you can have a pair of single-egress doors as an entrance to the suite in a smoke compartment barrier. Under section 18.3.7.6 of the 2012 LSC, all new cross-corridor doors serving a smoke compartment barrier must be the double egress type. But from your description, it appears these new doors would not be cross-corridor doors, but would be corridor entrance doors to the suite.

These new doors would have to latch because they are corridor entrance doors to a suite, even though they serve a smoke compartment barrier.

Suite Boundary

Q: We have a suite inside of a smoke compartment. We are trying to find out if the dividing wall needs to be the same as the 1-hour smoke barrier.

A: According to section 19.2.5.7.1.2 of the 2012 LSC, the boundary of a suite has to meet the requirements for corridors. This means, if the smoke compartment is not fully protected with sprinklers, then the corridor walls must be 30-minute rated, smoke-resistant, and extend from the floor to the deck above. If the smoke compartment is fully protected with sprinklers then the corridor walls only have to be smoke-resistant and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke. Therefore, the suite perimeter walls would have to be the same as the corridor walls.

It is possible however, that one wall can serve two purposes, so the suite wall could also be a smoke barrier as long as the wall meets the requirements for both purposes.

Keep in mind that a suite is nothing more than a room, although it is a large room with a lot of smaller rooms inside. Therefore, all corridor entrance doors into the suite must positively latch, and the path of egress cannot take you from a corridor into a suite to get to an exit.