Fire Alarm Audible Devices in Physician Sleep Rooms

Q: We have audible notification devices for the fire alarm system installed in our physician sleep rooms. We have a physician requesting the one in his area be removed. Are we permitted to remove the audible devices or do we have to have them?

A: Well…. I would certainly remove any audible alarm notification devices from a physician sleeping room, but there are some surveyors who are sticklers for them. Here is the reason why:

A physician sleeping room on a patient unit would be considered a mixed occupancy as the physician sleeping room would have to meet chapter 29 Existing Hotels & Dormitories. Section 29.3.4.5 of the 2012 Life Safety Code requires an approved single-station smoke alarm in every sleeping room. A smoke alarm is different than the typical smoke detector in the hospital. The smoke alarm is required to have an audible device when the smoke alarm is activated it will alert the individual in the room. So, technically, the audible device is required and some surveyors actually require it.

However, since the sleeping room is in a hospital, most accreditation organizations allow a hospital smoke detector to be installed in the sleeping room in lieu of a smoke alarm since there is staff on duty that would wake any sleeping physicians in the event of a fire. But, not all surveyors and AHJs see it that way and actually require the smoke alarms with audible devices to be installed.

But perhaps the saving grace for you is the smoke alarm in the physician sleeping room is not required to be connected to the building fire alarm system (a smoke detector would be, but not a smoke alarm) so you don’t have to have a building audible notification device in the sleeping room which would activate everytime the fire alarm system is activated. Just have a single-station smoke alarm that has an audible signal installed, which will only activates if the a fire develops in the sleeping room.

By the way, section 29.3.6.2.2 and 29.3.6.2.3 requires a fire-rated door to that room if the corridor is not sprinklered, and the door needs a closer.

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.