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Fire Protection - Clinical Impact

This content includes information linking Environment of Care and Life Safety Code deficiencies and their impact on patient care and patient safety.

EC.02.03.05: The organization maintains fire safety equipment and fire safety building features.

EC030205 Fire Protection 

Clinical Impact - Features of Fire Safety

Clinical staff must have a basic understanding of the Features of Fire Safety as they work in the healthcare environment. In this environment we do not evacuate immediately in a fire or other emergency condition, but rather ‘defend in place’ (See Building Compartmentation Discussion below) by keeping the patients in their beds and rooms. This is possible because of how our hospitals are built, the protection such as sprinklers, and other features of fire safety. Some of the features of fire protection are obvious to the staff and public, others are not. For example, doors held open by magnetic hold opens close, audible alarms sound and visual strobes activate, which are obvious. Dampers inside the duct work is not. Those components that are designed to alert occupants of an emergency condition must be understood by all staff.

The Joint Commission requires each organization to have a specific fire response plan and exercise this plan by conducting fire drills once per shift per quarter.  Included in the fire drill is a requirement to activate the fire alarm system, which includes audible and visual alarms. It is generally felt by many that these fire drills are redundant, but as a code requirement, they are not optional.

In every post-event debrief I have ever conducted I have consistently heard from clinical staff that although they did not appreciate the fire drills as they never seemed ‘convenient’ those same staff then stated that is was these very drills that enabled them to know exactly what to do to protect and aid their patients.  Occupant notification, which seems disruptive, is designed to alert staff as soon as possible so they can implement the fire response plan, as well as establishing compliance with the Joint Commission and CMS.

The Joint Commission requires twenty systems be tested or inspected as often as weekly, monthly, quarterly and up to annually. Many of these system tests affect the daily activities of the healthcare organization as features are activated. Doors held open by magnetic hold opens close, audible alarms sound and visual strobes activate. Although Facilities tries to combine as many activities into each test to reduce disruption, they are dependent on their clinical colleagues to reassure patients that the alarm they are hearing is a test that confirms the reliability of the fire protection system. It is also a great time for staff to reflect on what would they do in an actual event. (NOTE: this standard does not require these types of fire safety equipment and building features, however if these types of equipment or features exist, then they must be tested as required in the standard.)


The Joint Commission and CMS, as authorities having jurisdiction who have adopted the National Fire Protection Association Life Safety Code, include enforcement is part of accreditation. CMS has adopted the NFPA codes by statute, which is why issues like compliance with these Codes is not an option but a requirement.

Many of these Features of Fire Safety are automatic and do not require staff intervention. Others, such as using portable fire extinguishers are dependent on staff to understand how to use them. It is crucial all staff have a basic understanding of how these features work to protect them and their patients or visitors.  The tests and inspections ensure the reliability of the systems, the staff training ensures staff are able to respond. Together we have an environment to protect patients.

Have you ever seen a movie where someone pulls a manual pull station and the sprinkler system starts and everyone is in a "glorious shower"? Or a movie where a fire occurs in one office, but the entire sprinkler system activates?

The Truth

  • A sprinkler is a local device designed to activate when heat (i.e. fire) is sensed in the immediate area, and when the heat reaches a pre-determined temperature the individual sprinkler head activates. In larger fires multiple heads may activate, depending on the fire conditions. The entire building sprinkler system does not activate until a fire risk is evident (“Glorious Shower”).
  • The truth is that when a water charged sprinkler system is commissioned additives are added to reduce corrosives that can rust or otherwise deteriorate the sprinkler piping system. These additives, after a period of time, become rather strong smelling, and the initial water discharged is brackish, black and foul smelling, certainly something you would not want to stand under.
  • The manual pull station is designed to activate the fire alarm panel and announce an emergency condition in the area. These are addressed, so the fire alarm panel can identify where assistance is required. It does not activate the sprinkler system.

Building Compartmentation Discussion

Healthcare occupancies are designed to protect occupants by defending in place, rather than evacuation (as in business occupancy). To accomplish this, healthcare occupancies are designed with certain features that protect the occupants. For this to occur, all features of fire safety, including the building construction and fire suppression/alarm systems, need to be fully operable.

In 1978 the Joint Commission released an LSC model called the Unit Concept. This model was mainly developed to educate the surveyors about the LSC, but when it caught on, the Joint Commission published the concept and used it to teach health care professionals about code compliance. In a health care occupancy, because of the building type and staff-to-patient ratios, the reaction to a fire is to "defend in place."

The Unit Concept includes the following:

  • Building unit – The compartmentation of the total structure, including appropriate building construction/type.This is the largest of all units, as it has to do with how well the building will perform in a standard fire. It also includes fire barriers and floor assemblies. Features such as roof construction, fire detection and suppression systems and exiting methods contribute to the building unit.
  • Room unit – Individual rooms are the first unit of defense, and the room unit is the smallest of the units in the Unit Concept. The term room unit is somewhat misleading in a non-sprinklered compartment, as there is no requirement for separation between patient rooms. In a sprinklered environment, due to the rapid response of the sprinkler head, the patient room certainly is the first unit of defense. In a non-sprinklered compartment, the original concept of the LSC was to separate use areas (rooms) from the exit access (corridor) to provide an environment free from the products of combustion.
  • Compartment – Based on the size of a smoke compartment (22,500 square feet maximum), this unit component includes rooms and corridors, and creates areas that may be accessed horizontally, which is the preferable method to rapidly move patients. The compartment unit includes all the requirements for separating an institutional occupancy into smoke compartments. The maintenance elements include wall integrity, smoke dampers, and door hardware. Smoke compartmentalization is one of the most important features in the LSC, and a facility must be diligent in making sure these features are properly maintained. The smoke barrier is identified as having 30 minute Fire Resistive Rated assemblies, and is easily identified as having cross-corridor doors without latching hardware, but with door closures and a gap at the meeting edges of < 1/8”. The smoke barrier assembly reaches from the outside wall to the other outside wall, from the deck above to the floor, and is to be without unprotected openings. A fire barrier is similar, however a fire barrier must meet certain criteria related to how long the assembly can resist the penetration of fire from one side to another (typically either 1 hour construction with 45 minute doors; or 2 hour construction with 90 minute doors). Like the smoke barrier, the fire barrier reaches from the outside wall to the other outside wall, from the deck above to the floor is to be without protected openings. The major difference is that a two hour rated fire barrier can separate building occupancies, provided certain criteria is met. This includes not exiting from a higher occupancy to a lesser occupancy in a fire situation (i.e. not exiting from a hospital occupancy through a business occupancy). However, in certain situations, it is allowable to exit from a business occupancy through a healthcare occupancy.
  • Floor assembly – Floor assemblies separate floors, with a fire rating determined by the building construction type and height of the building. The floor assembly unit contains the floor slab and all vertical penetrations of that slab. (If the smoke or fire barriers fail, then the floor assembly becomes the next unit of defense. Vertical penetrations of floor assemblies that are improperly maintained can cause smoke and fire to spread vertically throughout the building.) With the necessity to supply many mechanical, electrical, and patient support systems through chutes and shafts, and to provide vertical access by stairs and elevators, a facility must be diligent in making sure vertical penetrations are properly sealed and access panels are appropriately rated. Floor assemblies vertically separate occupancies.
  • Exit – A primary feature of life safety is the ability to exit a compartment and, as appropriate, to exit the building. Exits must be maintained so that if a fire (or other incident) occurs, the rapid movement of patients and visitors can take place. In a defend-in-place occupancy such as a health care occupancy, the likelihood of having to totally evacuate a building is rare, but the possibility still exists. Even in a fully sprinklered building, the need to use the means of egress and exits may be necessary due to other internal or external disasters. When an occupant enters this type of component and leaves an unsafe environment, he or she is considered to be out of harm's way. Therefore, exit areas must be considered a priority in a PM Program. The Joint Commission will evaluate business occupancies in regard to the accessibility of the exits.  No exit shall be compromised in a business occupancy.