Doors to Operating Rooms

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 19.3.2.1 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 19.3.2.1.3) and positive latching (see 19.3.2.1.2, which references 8.4.3.2 which references 7.2.1.5.10).

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.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.