Audit requirement for Fire Safety Compliance and Protection in Hospitals

Defining health care environments

NFPA 101: Life Safety Code defines several types of healthcare-related facilities: hospitals, ambulatory care centers, and doctor’s offices. These all have their own requirements and are defined as follows:

From the 2018 edition of NFPA 101

3.3.150 Hospital. A building or portion thereof used on a 24-hour basis for the medical, psychiatric, obstetrical, or surgical care of four or more inpatients. Ambulatory Health Care Occupancy. An occupancy used to provide services or treatment simultaneously to four or more patients that provides, on an outpatient basis, one or more of the following: (1) treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; (2) anesthesia that rends the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; (3) treatment for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others.* Business Occupancy. An occupancy used for the transaction of business other than mercantile. [A. … Doctors’ and dentists’ offices are included, unless of such character to be classified as ambulatory health care occupancies.] Health Care Occupancy. An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants’ control.

The Johns Hopkins Hospital is certainly defined as a hospital under NFPA 101. Source: Business Insider

Understanding functional systems in hospitals

Hospitals function like a dynamic, living organism, made up of multiple systems working together. It is critical to the success of facility operations that various systems remain in working condition, including gas, ventilation/HVAC, electrical, communications, plumbing, fire protection, and operations. Each system is classified by the risk its failure poses to losing lives or causing injuries or discomfort. NFPA 99 outlines four risk categories:

From the 2018 edition of NFPA 99

4.1* Risk Categories. Activities, systems, or equipment shall be designed to meet Category 1 through Category 4 requirements, as detailed in this code.

4.1.1* Category 1. Activities, systems, or equipment whose failure is likely to cause major injury or death of patients, staff, or visitors shall be designed to meet Category 1 requirements as detailed in this code.

4.1.2* Category 2. Activities, systems, or equipment whose failure is likely to cause minor injury of patents, staff, or visitors shall be designed to meet Category 2 requirements, as detailed in this code.

4.1.3 Category 3. Activities, systems, or equipment whose failure is not likely to cause injury to patients, staff, or visitors, but can cause discomfort, shall be designed to meet Category 3 requirements, as detailed in this code.

4.1.4 Category 4. Activities, systems, or equipment whose failure would have no impact on patient care shall be designed to meet Category 4 requirements, as detailed in this code.

Each category of system must meet the applicable requirements of NFPA 99, and specific systems may have a separate standard for installation and maintenance.

Gas and Vacuum Systems. The installation of these systems is outlined in Chapter 5 of NFPA 99. Additionally, cryogenic fluids for oxygen supply must comply with NFPA 55: Compressed Gases and Cryogenic Fluids Code.

Electrical Systems. All electrical installations must comply with NFPA 70: National Electrical Code (NEC)® and the specific requirements of Chapter 6 of NFPA 99.  When generator sets are utilized where an alternate power source is required, they must be installed and maintained following NFPA 110: Standard for Emergency and Standby Power Systems.

Information Technology and Communications Systems. Fiber and copper installations must comply with NFPA 70: National Electrical Code (NEC). All other requirements for these systems are outlined in Chapter 7 of NFPA 99.

Plumbing. These systems must comply with the requirements listed in Chapter 8 of NFPA 99.

Heating, Ventilation, and Air Conditioning (HVAC). These systems are addressed in Chapter 9 of NFPA 99. Ductwork and air supply must be installed in accordance with NFPA 90A: Standard for the Installation of Air-Conditioning and Ventilating Systems. All gas systems other than medical equipment must be provided with ventilation that meets requirements in NFPA 55: Compressed Gases and Cryogenic Fluids Code.

Other areas. Other spaces within a hospital setting should be protected per the following standards and requirements:

Hyperbaric facilities should be constructed and protected following Chapter 14 of NFPA 99.

Laboratories and –clean rooms shall comply with NFPA 45: Standard on Fire Protection for Laboratories Using Chemicals.

Waste and linen chutes must meet the requirements of NFPA 82: Standard on Incinerators and Waste and Linen Handling Systems and Equipment.

To promote hospital fire safety and prevent surgical fires, “the U.S. Food and Drug Administration has launched an education program for medical professionals using safeguards found in NFPA codes and standards.” Source: NFPA Journal

Fire safety guidelines for hospitals

Individual fire protection and life safety measures are part of a system. No single fire protection feature can be effective without other supporting elements. For example, a fire sprinkler system without an alarm or compartmentation may not be able to do its job adequately. Without an alarm, there would be no notification that a fire is occurring and that action should be taken. Without compartmentation, the fire could grow unimpeded, and it might quickly overcome the capabilities of a fire sprinkler system.

In the following paragraphs (and our downloadable hospital fire safety checklist), we examine the NFPA codes and standards references that ensure fire protection and life safety systems work as intended. These items include compartmentation, fire sprinklers, specialized fire suppression systems and extinguishers, fire alarms, backup power, and safety operations and plans.

Compartmentation in medical facilities

Chapter 18 of NFPA 101 outlines the construction and design requirements for a medical structure. Many of these specs focus on compartmentation, which is –a passive fire protection system that prevents or slows the spread of fire by walling it off. Included in the rules is the required fire rating of walls, doors, and corridors for patient rooms, operating areas, special hazard spaces, and egress paths.

These surfaces must remain intact to ensure that their required fire-resistance rating is in place. Any openings in a fire-resistance-rated wall must be adequately sealed or protected. This requires appropriately rated fire doors, windows, and transfer grilles.

From the 2018 edition of NFPA 101 General. Every opening in a fire barrier shall be protected to limit the spread of fire from one side of the fire barrier to the other.

As hospital facilities are maintained and updated, various trade workers and equipment have to penetrate the fire-rated walls; these holes may be for IT/communications cables, ductwork, or a myriad of other items. Each opening that penetrates the fire-rated barrier must be properly sealed and fire-stopped. And areas that are prone to penetrations should be documented and frequently inspected.

From the 2018 edition of NFPA 101* Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.

Fire sprinklers in hospitals

Fire sprinklers must be installed throughout healthcare occupancies. These systems are installed following NFPA 13: Standard for the Installation of Sprinkler Systems, and they are maintained according to NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 outlines the required inspection, testing, and maintenance (ITM) frequency and procedures. Major system components are required to be inspected quarterly, semi-annually, and annually. At each of these intervals, specific items must be maintained and tested. There are also weekly and monthly inspection requirements for items that must only be visually inspected—these components include gauges, valves, private hydrants, and fire pumps.

–Read our series about commercial fire sprinkler inspection requirements to learn more.

The primary concern for facility managers is ensuring that these inspections, maintenance, and testing are completed by a qualified fire sprinkler professional and documented. Careful recordkeeping of sprinkler system ITM is a critical component to ensuring system reliability, and it is required for any form of agency accreditation.

Fire extinguishers and specialized fire suppression systems

Fire extinguishers are required throughout the building. –These must be selected, placed, inspected, tested, and maintained following the rules in NFPA 10: Standard for Portable Fire Extinguishers.

Any commercial kitchen and cooking facilities in a medical facility must be protected with a –hood and fire suppression system, which requires semi-annual inspections, testing, and maintenance. Additionally, the filters and exhaust ductwork that make up the hood system require regular cleaning—the frequency of which is based on the amount of grease that is used in the cooking process. These specific requirements are outlined in NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

Hospitals are provided with an exception to protecting cooking appliances when “residential” cooking equipment is employed for light use, food warming, and reheating. This allows for using appliances such as microwaves, hot plates, or toasters without requiring them to be under a hood or protected with a dedicated fire suppression system.

Fire alarms in medical facilities

NFPA requires a fire alarm system throughout the facility. NFPA 72: National Fire Alarm and Signaling Code, outlines the installation and ITM requirements for these systems. A facility manager should understand the basic operation of fire alarms and what the various signals may mean. Quarterly, semi-annual, and annual system inspection, testing, and maintenance are required, and diligent records must be maintained of all ITM work and results.

Generator sets and alternate power sources

NFPA 99 introduces the term EES: essential electrical systems.

From the 2018 edition of NFPA 99

3.3.51* Essential Electrical System. A system comprised of alternate sources of power and all connected distribution systems and ancillary equipment, designed to ensure continuity of electrical power to designated areas and functions of a healthcare facility during disruption of normal power sources, and also to minimize disruption within the internal wiring system.

Based on the risk category of the healthcare space (see above), an alternate power source, such as a generator, may be required to maintain the EES:

Category 1 spaces required a Type I EES.

Category 2 spaces can utilize either a Type I or a Type II EES.

Category 3 and 4 spaces do not require an EES.

Where required, the EES must meet the requirements of NFPA 110: Standard for Emergency and Standby Power Systems, for a Type 10, Class X, Level 1 generator set.

The alternate power source used to maintain an EES must be maintained following the requirements of Chapter 8 of NFPA 110. This testing requires the generator set to be run least 12 times per year, and the critical operating components must be visually inspected. Records of these run times and visual inspections must be maintained and made available to the inspecting authority having jurisdiction (AHJ).

From the 2018 edition of NFPA 99

6.7.4. Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Operations and plans

Healthcare facilities must maintain emergency and evacuation plans, and employees must be regularly trained on these plans and their roles within them. Emergency plans should include instructions for fire emergencies and general building evacuations.

Quarterly evacuation drills are required for each shift, and records of these drills must be maintained. Additionally, hospital staff should be aware of and sustain general housekeeping standards. These activities include maintaining clear access to exits, enforcing “no smoking” policies, making sure decorations in halls and patient rooms are fire resistant and do not exceed allowed limits, and ensuring soiled linens and trash are regularly emptied and not permitted to accumulate beyond allowed maximums (0.5 gallons per room, 32 gallons total in a protected area).

RACE procedures for hospital fire safety. Source: Windsor Regional Hospital

Hospital fire safety: Complicated rules, but a fantastic track record of safety in the US

The last of the major hospital fires in the United States occurred in the 1980s. And in that era, nearly 8,000 fires occurred in hospitals annually. Today’s relatively low frequency of hospital fires—a drop of about 86% in a few decades—and the extremely low fatality rate are due to measures and systems like compartmentation, active fire suppression, fire alarms, and safe and reliable alternative power supplies. Additionally, the inspections and accreditation process for hospitals places an extremely high priority on hospital fire safety.

Nevertheless, it’s a complicated and time-consuming job to track and maintain all of the required systems that are necessary to ensure a fire-safe medical facility. Our downloadable hospital fire safety checklist makes things a little easier.

It points you to the exact sections of NFPA 101 and NFPA 99 that govern various installation, inspection, testing, and maintenance requirements and helps you ensure that all items, tasks, and documentation are in place. This resource tells you where to look in these huge NFPA documents, helping hospital facility managers and other stakeholders prepare for audits and fire inspections.


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