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