HOSPITALS HAVE PROVIDED SAFE HARBOR for patients for many years. Compartmentation using construction to contain fire risks allows patients in hospitals and residents in long-term care facilities to remain in place during fire emergencies. The ability to protect patients in place reduces the need for relocation or evacuation and allows for a continuation of medical care.
In 1995, The Joint Commission, which accredits more than 20,000 organizations, including 4,800 hospitals, created the Statement of Conditions™, a proactive approach to assessing facilities. The approach provides a method to manage known deficiencies, beginning with interim life safety measures and extending to the resolution of those deficiencies with a plan for improvement. Despite this approach, problems related to improper fire and smoke barriers remain some of the top deficiencies in health care facilities, as identified by The Joint Commission (see "The Compliance Factor," sidebar).
In recognition of the ongoing magnitude of these issues, The Joint Commission (TJC) has partnered with several other organizations to create the Barrier Management Symposium, a training program for those responsible for making sure that these systems are functional and comply with the intent of NFPA 101® , Life Safety Code® . The program includes participation from TJC, the American Society for Healthcare Engineering (ASHE), the Firestop Contractors International Association, Underwriters Laboratories, the Door & Hardware Institute, the fire damper industry, and the fire-rated glazing industry. It is anticipated that three to four Barrier Management Symposiums will be hosted by ASHE chapters each year. (For more on the symposiums, visit ashe.org.)
The goal of the Barrier Management Symposium is to educate those responsible for managing the health care built environment and ensuring that the barrier systems crucial for a "defend in place" model are properly maintained. TJC believes that when the people who are responsible understand the importance of these systems, they will be able to provide a safer health care environment for patient care delivery and gain the knowledge to more effectively comply with requirements.
THE GOOD, THE BAD, & THE UGLY Not all through-penetrations between compartments are created equal, and construction methods must be sure to provide adequate barrier protection. Use of qualified contractors and a thorough inspection regimen can help minimize such problems. (Photos: Koffel Associates)
Problems start with design and construction
The first step in providing effective compartmentation in health care facilities is proper design and construction. Unfortunately, some of the problems noted by TJC surveyors have existed since initial construction of the facility. In some instances, barriers are provided that are not needed, or barriers are not properly represented on the construction documents. From a code compliance perspective, there is a significant difference between assemblies referred to as fire walls, fire barriers, and fire partitions. Likewise, smoke barriers are not the same as smoke partitions or walls designed to resist the passage of smoke.
TJC surveyors and other regulatory officials evaluate facilities based on the nomenclature as signed to an assembly. Design professionals and facility managers need to make sure that the proper terminology is used on their life safety drawings (see "Necessary Detail," below).
The Joint Commission requires that Life Safety Drawings contain the following information to be compliant:
• A legend clearly identifying fire safety features
• Hazardous area locations
• Fire-rated barrier locations
• Smoke barrier/smoke compartment locations
• Sleeping and non-sleeping suite boundaries and sizes
• Linen and waste chute locations
• Shaft locations
• Approved equivalencies
• If the building is partially sprinkler protected, a means of identifying which
portions are fully sprinkler protected
The second issue is to ensure that the assemblies are properly constructed. Proper commissioning of the building should identify assemblies that lack the continuity required by the applicable codes. Examples include through-penetrations that are not properly protected, dampers that are not installed in accordance with manufacturers’ installation instructions, and door assemblies that are not installed in accordance with reference standards such as NFPA 80, Fire Doors and Other Opening Protectives.
Methods that can be used to minimize such problems include using qualified contractors and making certain that thorough inspections are performed during the construction and commissioning process. Numerous programs exist that can be used to qualify contractors and to ensure that proper inspections are performed — for example, see A.126.96.36.199 in the 2012 edition of NFPA 101. The use of these methods can help facility managers proactively identify and resolve deficiencies prior to releasing contractors from their contractual obligations.
For example, in one new hospital the maximum ¾-inch (1.9-centimeter) clearance under fire doors could not be met due to the way the floor slab was poured. In order to achieve a clearance that did not exceed ¾ of an inch, a portion of the door would rub against the floor. After-market products were evaluated and subsequently installed to comply with the maximum clearance requirements at a cost to the facility, since the deficiencies were noted post-construction. If this hospital had utilized a qualified contractor or an inspection program during commissioning, the facility would not have had to incur this cost.
It is well understood that many health care facilities are in a constant state of change. As such, it is critical that people recognize the location and function of fire barriers and smoke barriers.
Maintaining accurate life safety drawings is a start, but not everyone will reference the drawings before engaging in construction activity. As such, facilities have found it beneficial to mark the walls of fire barriers and smoke barriers.
The NFPA Life Safety Technical Committee on Fire Protection Features has discussed the possibility of requiring such marking in the past but has chosen not to include such a requirement in the Life Safety Code, in part due to challenges associated with standardizing such markings and requiring them on all fire barriers and smoke barriers. However, this does not preclude a facility from implementing such a procedure as a best practice. Some other codes, such as the International Building Code, do require such markings.
The Compliance Factor
Compartmentation issues from TJC surveys conducted in 2013
As an accrediting body, The Joint Commission has the ability to track the level of compliance and identify problematic areas following its surveys of health care facilities. The top 10 findings most often scored in 2013 included two related to compartmentation: "General Requirements" (Standard LS.02.01.10) scored 46 percent of the time and was ranked fifth, and "Protection" (LS.02.01.30) scored 43 percent of the time and ranked seventh. The following is a breakdown of issues for each of these standards that resulted in findings.
Openings in two-hour fire-rated walls are fire rated for one and a half hours.
Doors required to be fire rated have functioning hardware, including positive latching devices and self-closing or automatic-closing devices. Gaps between meeting edges of door pairs are no more than 1⁄8-inch wide, and undercuts are no larger than ¾ inch.
Ducts that penetrate a two-hour fire-rated separation are protected by dampers that are fire rated for one and a half hours.
The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material. (Note: Polyurethane expanding foam is not an accepted fire-rated material for this purpose.)
All hazardous areas are protected by walls and doors in accordance with the 2000 edition of NFPA 101®, Life Safety Code®.
Smoke barriers extend from the floor slab to the floor or roof slab above, through any concealed spaces (such as those above suspended ceilings and interstitial spaces), and extend continuously from exterior wall to exterior wall. All penetrations are properly sealed.
Doors in smoke barriers are self-closing or automatic-closing, constructed of 1¾-inch or thicker solid bonded wood core or equivalent, and fitted to resist the passage of smoke. The gap between meeting edges of door pairs is no wider than 1⁄8 inch, and undercuts are no larger than ¾ inch. Doors do not have nonrated protective plates more than 48 inches above the bottom of the door.
Another common approach for recognizing the location of fire barriers and smoke barriers is to require permits when work is being performed above the ceiling, similar to a hot-work permit required for welding operations. The permit process can be used to educate individuals as to the location of the barriers and for facility personnel to verify that the work performed has not compromised the integrity of the barrier, before the individual has completed the project. Any deficiencies can then be corrected by the contractor or individual who caused the problem instead of the facility having to incur the cost of remediation sometime in the future.
Some facilities go beyond issuing above-ceiling permits by also requiring that individuals who are issued a permit be identified with a colored arm band, a ladder of a certain color, or some other clearly visible identifier. These identifiers increase the effectiveness of the program by allowing all staff within the facility to help monitor construction activities. Facility staff is instructed to report any individuals who are observed working above the ceiling without the proper identifier. It is important to note that such programs need to apply to both outside contractors and facility personnel.
In addition to construction activities that may compromise existing barriers, post-occupancy changes may also result in a need to add new barriers or eliminate the need for existing barriers. For example, additional fire barriers may be required if the use of a space changes so that it becomes a hazardous area.
Code requirements are often misapplied when fire barriers or smoke barriers are eliminated. Paragraph 188.8.131.52 of the Life Safety Code states that existing life safety features must not be removed or reduced where such feature is a requirement for new construction. There have been instances where facilities have incorrectly eliminated existing smoke barriers where the number of patients sleeping on the floor has been reduced to fewer than 30, which is the threshold at which smoke barriers are required for existing facilities in Chapter 19. But Chapter 18 still requires the smoke barriers for new construction.
Most facilities need to comply with codes other than the Life Safety Code, which is why a thorough code analysis should be performed before any existing feature is reduced or eliminated, and why permission should be obtained from all appropriate authorities having jurisdiction, including accrediting organizations and local code officials. (For more on the current Life Safety Code discussions regarding proposed changes to smoke compartment size in hospitals, see the NFPA 101 section of "In Compliance".)
Cost containment is important in any facility, including health care facilities. Unfortunately, current practices result in many health care facilities spending significant amounts of money attempting to comply with code requirements for fire barriers and smoke barriers. TJC data indicate that existing programs to address compliance have not been very effective. Increasing efforts to ensure that health care facilities are properly designed and constructed, combined with effective post-occupancy programs to prevent deficiencies from occurring, will help facilities save money while still providing properly maintained fire and smoke barriers.
George Mills, MBA, FASHE, CEM, CHFM, CHSP, is director of engineering for The Joint Commission. William E. Koffel, P.E., FSFPE, is president of Koffel Associates, Inc., and chair of the Correlating Committee on Safety to Life and the NFPA 25 technical committee.