CHAPTER 8

SECTION 13

Healthcare Occupancies
Revised by

Daniel J. OConnor

n todays business environment, healthcare, medical care, and personal care services have evolved such that there is a wide variety of facilities and business operations delivering healthcare to the general population. As a result, there are varying levels of risk among the facilities that offer healthcare and medical services. Within NFPA 101, Life Safety Code, there are several types of occupancies where people may receive some form of healthcare, medical or personal care service. These include Healthcare occupancies Ambulatory healthcare occupancies Residential board and care occupancies Business occupancies

The focus of this chapter is on those facilities that pose greater risks due to the impairment of occupants and/or lack of ambulatory capabilities of the occupants. Specifically, this chapter addresses healthcare occupancies and ambulatory healthcare occupancies; however, some brief discussion of residential board and care, and business occupancies is warranted, as there are important distinctions that should be understood and considered when applying the requirements of NFPA 101. Healthcare facilities are used for the treatment or care of persons suffering from physical or mental illness, disease, or infirmity, and for the care of infants, convalescents, or aged persons. These facilities provide sleeping accommodations for occupants who may be incapable of self-preservation because of physical or mental disability or age. Some buildings that house healthcare occupants have security measures that limit freedom of movement. In recent years, facilitiessometimes called ambulatory healthcare facilitieshave been developed to provide medical treatment on an outpatient basis. Although patients might be placed under general anesthesia or other treatment that would render them incapable of self-preservation, they are not housed overnight. Occupants exhibit some characteristics of people in business occupancies and some characteristics typical of people in healthcare facilities. In the last several years, tremendous growth has occurred in an occupancy related to healthcare: residential board and care facilities. These facilities are commonly called assisted living

facilities, personal care facilities, and so on. Residential board and care facilities provide personal care to occupants in a residential setting. The residents abilities to respond to a fire threat differ greatly from patients in healthcare facilities. The safeguards appropriate for healthcare facilities should be applied only when a facility meets the definition in NFPA 101, of a healthcare facility. In many facilities the presence of doctors providing diagnosis and treatment for patients may suggest that the facility is a healthcare occupancy. This may not be the case, as most doctors offices and birthing centers are classified as business occupancies when meeting the definitions and criteria defined in NFPA 101. Where doctors offices solely provide outpatient care and are physically separated from facilities housing inpatient treatment and care areas, such offices can be classified as business occupancies, although associated with the operations and management of a healthcare occupancy. Additionally, in recent years there has been a significant growth in facilities known as birth centers. These facilities do not pose the risks associated with healthcare occupancies as they are intended for low-volume service for healthy, childbearing women, and their families, who are capable of evacuating in the event of a fire. Such facilities should meet the definitions for birth center and business occupancy given in NFPA 101; otherwise the facility may be a healthcare occupancy. This chapter describes the characteristics and fire hazards of healthcare facilities. It specifically discusses the characteristics of the healthcare occupant and the fire safety features that all healthcare facilities should provide. Additional information relating to healthcare facilities can be found in Section 12, Chapter 3, Interior Finish; Section 12, Chapter 5, Confinement of Fire in Buildings; Section 13, Chapter 9, Board and Care Facilities; and Section 13, Chapter 26, Protection of Electronic Equipment.

OCCUPANCY CHARACTERISTICS
Occupants of healthcare facilities are generally presumed to be incapable of self-preservation. A significant percentage of occupants in hospitals and nursing homes are incapable of selfevacuation or are ambulatory but incapable of perceiving a fire threat and choosing a rational response. There are three types of care in most modern hospitals: (1) ambulatory, (2) general, and (3) intensive care. Given proper

Daniel J. OConnor, P.E., is vice president of Schirmer Engineering Corporation in Deerfield, Illinois. He is chair of the NFPA Technical Committee on Health Care Occupancies.

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directions, unless smoke or heat is intense, ambulatory patients can make their own way to safety. General care patients may be transported on stretchers or in wheelchairs with some difficulty; horizontal and even some vertical movement is generally possible, although independent evacuation is not. Patients in intensive care are likely to be connected to various life support devices, making movement for even short distances very difficult and evacuation almost impossible without further endangering these patients lives. Occupants of nursing homes vary from geriatric residents who are capable of evacuation with limited assistance to residents who are comatose and require close supervision with evacuation being very difficult. Todays nursing home resident is less ambulatory and requires more medical care than a resident of even 10 years ago. The significant increase in the number of assisted living facilities has made the typical intermediate care nursing home resident of yesterday an assisted living resident today. Because some occupants are incapable of movement or slow to evacuate, a healthcare facility resembles a ship at sea: it is better to keep the fire from the patient than to remove the patient from the fire. Thus, occupants must be defended in place. As a result, healthcare facility design and operation must incorporate methods by which a fire can be detected early, contained, and fought rapidly and successfully. Accomplishing this requires careful planning of the healthcare facility and its day-to-day operation. NFPA 101, widely used to establish minimum requirements for life safety from fire within healthcare facilities, sets forth criteria based on the following general principles: Fire-resistive construction Subdivision of spaces, known as compartmentation Protection of vertical openings Provision of adequate means of egress Provision of exit marking, exit illumination, and emergency power Limits on the use of interior finish materials Fire alerting facilities Control of smoke movement Protection of hazardous areas Adequate protection of building service equipment Control of fuel loads Operational features

older adults. These causes totally dominate the ignition side of the life safety problem in these properties, although other causes, notably failures in electrical distribution systems, appliances, and other equipment, are also important in property damage (Tables 13.8.1 through 13.8.4). More and more healthcare facilities are establishing smokefree environment policies. In addition, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires facilities to establish a no-smoking policy. As the result of prohibiting or controlling smoking in healthcare facilities, a new phenomenon has developed: visitors giving smoking materials to patients and residents without the healthcare staffs knowledge. Most fatalities in healthcare fires are so close to the point of origin that their locations are coded as intimate with ignition (Table 13.8.5). Most fatalities that occur in the room where a fire begins turn out to have been intimate with ignition. Most intimate-with-ignition fire deaths begin on the victims clothing or in the mattress, bedding, or upholstered furniture on which they were lying when the fire began.

FIRE LOADS
Studies show relatively low fuel loads within most spaces in healthcare facilities. Fire duration varies from approximately 20 min for patient areas to several hours, depending on the space involved. A study by the National Bureau of Standards [now the National Institute of Standards and Technology (NIST)] conducted in 1942 involving three hospitals revealed an average fuel load of 5.7 lb/ft2 (30 kg/m2).1 Fuel loads for typical spaces are indicated in Table 13.8.6. A 1980 study of fuel loads in a U.S. Navy hospital confirms the relatively low fuel loads for general hospital areas but indicates that higher fuel loads may be anticipated in some spaces such as medical libraries, X-ray file rooms, linen storage, and general storage rooms. Further, the increased use of disposables and modern medical record storage practices are likely to result in above average fuel loads. These areas may contain fuel loads sufficient for fires from 1- to 3-hr duration. However, such spaces represent a small percentage of total floor area.5 A major portion of the floor area of healthcare facilities is used for patient sleeping or treatment rooms. Fuel loads for such spaces are low. For example, fuel loads in nursing homes have been estimated at 2.5 to 3 lb/ft2 (10 to 15 kg/m2).2 NIST surveys indicate that fuel loads for hospital patient rooms approximate 4 lb/ft2 (20 kg/m2) and that the combustible load in patient sleeping areas ranges from approximately 3 to 4.5 lb/ft2 (15 to 23 kg/m2).5 A study of a Navy hospital indicates fuel loads for sleeping rooms average 1 lb/ft2 (5 kg/m2) or less.13 Assuming standard time/temperature conditions, fire duration for patient areas and a majority of other occupied spaces would be less than 30 min.

Total building fire protection for life safety is more necessary in healthcare facilities than in other occupancies because of the nature of the occupants. At the same time, exits are slightly less important. The first principle of designing a fire safe healthcare facility must be that safety must not depend wholly upon any single safeguard.

IGNITION SOURCES
In 19941998, smoking materials, both lighted tobacco products and implements used to light them, and incendiary and suspicious acts accounted for 75 percent of deaths and 45 percent of injuries in facilities that care for the sick, and for 54 percent of deaths and 33 percent of injuries in facilities that care for

Disposables
The use of combustible disposable equipment and supplies is common in healthcare facilities. Disposables include bedding,

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TABLE 13.8.1 Causes of Fires and Direct Property Damage Structure Fires in Facilities that Care for the Sick, 19941998 Annual Averages (Unknown-Cause Fires Allocated Proportionally) Cause Other equipment Electronic equipment Separate motor or generator Cooking equipment Stove Portable cooking or warming unit Oven Appliance, tool, or air conditioning Dryer Electrical distribution Light fixture, lamp holder, ballast, or sign Incendiary or suspicious Smoking materials Open flame, ember, or torch Torch Heating equipment Other heat source Natural causes Exposure (to other hostile fire) Child playing Total 500 100 100 500 100 100 100 400 200 300 100 300 200 200 100 100 0 0 0 0 2600 Fires (20.2%) (3.6%) (2.5%) (18.0%) (5.1%) (5.1%) (2.4%) (15.6%) (6.1%) (12.1%) (3.9%) (10.5%) (7.6%) (7.4%) (4.5%) (5.1%) (1.3%) (1.2%) (0.7%) (0.4%) (100.0%) Property Damage (in Million Dollars) 1.8 0.4 0.1 0.3 0.1 0.1 0.0 1.4 0.4 1.4 0.1 2.1 0.2 1.2 0.7 0.4 0.2 0.2 0.1 0.0 9.2 (19.2%) (3.9%) (1.0%) (2.9%) (1.5%) (0.6%) (0.3%) (15.1%) (4.7%) (15.4%) (0.7%) (22.7%) (2.6%) (12.6%) (8.1%) (4.3%) (1.9%) (1.8%) (1.5%) (0.0%) (100.0%)

Note: These are fires reported to U.S. municipal fire departments and so exclude fires reported only to federal or state agencies or industrial fire brigades. Fires are expressed to the nearest hundred and property damage is rounded to the nearest hundred thousand dollars. Property damage figures have not been adjusted for inflation. The 12 major cause categories are based on a hierarchy developed by the U.S. Fire Administration. Sums may not equal totals due to rounding errors. Source: National estimates based on NFIRS and NFPA survey.

TABLE 13.8.2 Causes of Civilian Deaths and Injuries Structure Fires in Facilities that Care for the Sick, 19941998 Annual Averages (Unknown-Cause Fires Allocated Proportionally) Cause Open flame, ember, or torch Match Lighter Other equipment Biomedical equipment or device Incendiary or suspicious Smoking materials Cooking equipment Electrical distribution Appliance, tool, or air conditioning Natural causes Heating equipment Other heat source Total 3 2 1 1 1 1 0 0 0 0 0 0 0 5 Civilian Deaths (55.9%) (35.0%) (20.0%) (24.6%) (12.5%) (14.2%) (5.3%) (0.0%) (0.0%) (0.0%) (0.0%) (0.0%) (0.0%) (100.0%) Civilian Injuries 14 5 8 16 5 26 9 12 9 8 6 5 2 107 (13.4%) (4.9%) (7.5%) (15.3%) (4.3%) (24.3%) (8.0%) (11.5%) (8.4%) (7.3%) (5.5%) (4.6%) (1.7%) (100.0%)

Note: These are fires reported to U.S. municipal fire departments and so exclude fires reported only to federal or state agencies or industrial fire brigades. Civilian deaths and injuries are rounded to the nearest one. The 12 major cause categories are based on a hierarchy developed by the U.S. Fire Administration. Sums may not equal totals due to rounding errors. Source: National estimates based on NFIRS and NFPA survey.

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TABLE 13.8.3 Causes of Fires and Direct Property Damage Structure Fires in Facilities that Care for the Aged, 19941998 Annual Averages (Unknown-Cause Fires Allocated Proportionally) Cause Appliance, tool, or air conditioning Dryer Fixed area air conditioner Cooking equipment Stove Portable cooking or warming unit Oven Heating equipment Fixed area heater Central heating unit Smoking materials Electrical distribution Light fixture, lamp holder, ballast, or sign Fixed wiring Other equipment Incendiary or suspicious Open flame, ember, or torch Natural causes Other heat source Exposure (to other hostile fire) Child playing Total 900 600 100 600 300 100 100 300 100 100 300 300 100 100 300 100 100 100 0 0 0 3000 Fires (30.5%) (20.3%) (2.1%) (19.3%) (8.9%) (3.3%) (3.0%) (10.0%) (4.8%) (2.1%) (10.0%) (9.7%) (2.6%) (1.7%) (9.0%) (4.8%) (2.8%) (1.9%) (1.3%) (0.5%) (0.1%) (100.0%) Property Damage (in Million Dollars) 1.3 0.9 0.1 0.9 0.7 0.0 0.1 0.3 0.2 0.1 0.6 0.8 0.1 0.4 0.7 0.8 0.9 0.1 0.2 0.1 0.0 6.8 (19.7%) (14.0%) (0.9%) (13.1%) (10.2%) (0.3%) (1.1%) (4.9%) (2.3%) (1.5%) (8.9%) (12.1%) (0.8%) (5.5%) (10.6%) (12.3%) (12.7%) (1.3%) (2.7%) (1.2%) (0.5%) (100.0%)

Note: These are fires reported to U.S. municipal fire departments and so exclude fires reported only to federal or state agencies or industrial fire brigades. Fires are expressed to the nearest hundred and property damage is rounded to the nearest hundred thousand dollars. Property damage figures have not been adjusted for inflation. The 12 major cause categories are based on a hierarchy developed by the U.S. Fire Administration. Sums may not equal totals due to rounding errors. Source: National estimates based on NFIRS and NFPA survey.

TABLE 13.8.4 Causes of Civilian Deaths and Injuries Structure Fires in Facilities that Care for the Aged, 19941998 Annual Averages (Unknown-Cause Fires Allocated Proportionally) Cause Smoking materials Other equipment Biomedical equipment or device Unclassified special equipment Open flame, ember, or torch Lighter Incendiary or suspicious Cooking equipment Stove Other heat source Appliance, tool, or air conditioning Heating equipment Electrical distribution Child playing Exposure (to other hostile fire) Total Civilian Deaths 5 3 2 1 2 1 1 1 1 0 0 0 0 0 0 12 (39.5%) (24.7%) (18.0%) (6.0%) (18.7%) (8.0%) (6.9%) (6.1%) (6.1%) (4.1%) (0.0%) (0.0%) (0.0%) (0.0%) (0.0%) (100.0%) Civilian Injuries 54 25 2 5 12 5 21 11 6 2 65 29 20 1 0 241 (22.6%) (10.3%) (1.0%) (2.1%) (4.9%) (1.9%) (8.9%) (4.5%) (2.3%) (0.6%) (27.1%) (12.2%) (8.3%) (0.5%) (0.2%) (100.0%)

Note: These are fires reported to U.S. municipal fire departments and so exclude fires reported only to federal or state agencies or industrial fire brigades. Civilian deaths and injuries are rounded to the nearest one. The 12 major cause categories are based on a hierarchy developed by the U.S. Fire Administration. Sums may not equal totals due to rounding errors. Source: National estimates based on NFIRS and NFPA survey.

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TABLE 13.8.5 Facility Fires

Locations of Victims of Fatal Healthcare

Same Room as Fire but Not Intimate 6% 5 14 19 15 27 15 Not Same Room as Fire 18% 20 0 28 25 33 25

TABLE 13.8.6

Fuel Loads in Typical Healthcare Facilities

Average Combustible Contents (per sq ft) Exposed Woodwork and Floorsa 3.2 2.6 1.5 3.4 2.9 1.9 2.2 2.4 0.6 0.6 2.0 1.9 1.2

Property Class Facilities that care for the sick Hospitals Other or unknown type Facilities that care for older adults With nursing staff Other or unknown type All facilities combined

Intimate with Ignition 76% 75 86 53 60 39 60

Location Rooms (single) Corridors Waiting rooms Janitors closets and supplies Doctors offices Nurses offices and rooms Nurses infirmary Diet kitchens and dining rooms Laundries Laundries and clothes storage Dormitories Pharmacy, dispensary, and stores Lockers, toilets, and barber shops Approximate average for entire usable floor area of three hospital buildings surveyed

Movable Property 0.5 0.0 1.7 3.1 5.7 3.1 0.8 1.2 4.4 12.5 0.8 5.8 0.2

Total 3.7 2.6 3.2 6.5 8.6 5.0 3.0 3.6 5.0 13.1 2.8 7.7 1.4 5.7b

Source: NFPA analysis of data from 19801998 NFIRS and NFPA survey.

gowns, gloves, drapes, collection bags, tubing, dishes, glasses, syringes, needles, and many diagnostic and therapeutic instruments. All such items require packaging, which can add to the combustible load both before and after use.

Data Processing and Medical Records

Used to satisfy general business needs as well as to store patient records, data processing centers contain quantities of combustibles. These combustibles could expose high-value equipment, result in loss of vital records, and produce a fire that threatens occupants outside the data processing areas. Special protection should be considered for data processing centers. Healthcare facilities generate and store medical files in considerable quantity. Files stored in closed steel cabinets do not represent any significant increase in hazard over that typical of most areas. However, files stored on open shelving create a serious fire hazard. Large quantities of open-file storage should be treated as a severe hazard and should be separated by fire-rated construction and protected by automatic sprinklers.

a Combustible floor finish, where present, was in. linoleum; it was assumed to be the equivalent of 1 lb of combustible material, such as wood, per sq ft of floor area (4.88 kg/m2). Doors, windows, trim, mouldings, baseboards, and so on, are included. b This approximate average weight was computed from Table 16 on page 25 of the Bureau Report BMS 921. The value is somewhat high because the highest weight In each bracket of combustible contents was used in figuring it, that is, in the bracket 0 to 4.9 lb/ft2 (23.9 kg/m2), the value 4.9 lb (2.22 kg) was applied to the indicated area, and so on.

FIRE SEVERITY
Determining relative fire hazard involves considerations beyond total fuel loads. The arrangement of combustibles, their chemical makeup, and their physical state are all factors to be evaluated, in addition to room geometry, ventilation rates, fire compartment size, and fire protection facilities. Generally, the faster a fire develops, the greater its threat. Although the total fuel load in patient rooms remains low, the nature of the combustibles is important. Foam plastic decubitus pads, upholstered furniture, and polyurethane foam mattresses may not affect the length of time a fire will burn, but such items have affected the rate of fire growth. These types of products can cause fire to grow to a large size quickly. Fires that reach flashover produce acutely lethal atmospheres generating thousands of cubic feet of smoke per minute.

Such fires threaten fire-rated barriers and produce enough energy to drive smoke to remote areas. A fire that grows to full room size in a healthcare facility represents an unacceptable level of risk; there is a high likelihood that such a fire will result in injuries or fatalities if its origin is in the patient sleeping area. Therefore, every effort should be made to recognize and eliminate or adequately protect fuel arrangements that might produce such fires. Fire tests and actual fire experience have shown that certain common arrangements and types of fuels in patient rooms create especially hazardous situations because they are able to produce large fires in short time periods. In January 1976, for example, multiple-death fires in both the Wincrest and Cermak House nursing homes involved wooden wardrobes within patient sleeping rooms.3,4 Tests show that combustible wardrobe fires can result in acutely hazardous environments in as little as 120 s.5 A 1989 fire in a Norfolk nursing home resulting in 12 deaths originated in a foam plastic decubitus pad on a mattress

1382 SECTION 13 I Systems Approaches to Property Classes

in a patient sleeping room. The fire grew to flashover in less than 5 min.6 A 1985 fire in a Michigan hospice initially involved an upholstered chair. The fire caused eight deaths.7 Analysis of this fire established that flashover could have occurred in the room of origin in under 4 min. See Figure 13.8.1 for documentation of the analysis for the hospice fire. Any combination of finishes, combustible building materials, or contents and furnishings that could result in full room involvement or flashover in 5 min or less represents a severe fire hazard in a healthcare facility. Such spaces should always be protected by automatic sprinklers and separated by fire-rated construction. Computer fire models developed at NIST have been used to establish the rate of heat release required to produce flashover in a typical patient sleeping room. Under the worst circumstanceswhere the room door is partially opena 1-MW fire can cause flashover. When the room door is fully open, approximately a 2-MW fire is necessary to cause flashover. NFPA 101 suggests that upholstered furniture, mattresses, and wardrobes be constructed to produce a maximum rate of heat release of 250 kW. It also has been determined that when a fire grows beyond 250 kW in size, hazard thresholds are exceeded, and patients must be removed from sleeping rooms. Furnishings are frequently major contributors to fire growth. Recent developments make it possible to determine whether furnishings in a given environment can produce sufficient energy to cause full room involvement. A simplified equation for estimating the rate of heat release required for flashover to occur in a room8 is given by the expression Q E 750A h where Q C rate of heat release (kW) A C ventilation opening area [ft2 (m2)] h C the height of the opening [ft (m)]

Once the heat release rate required to produce flashover is known for a typical room geometry, such information can be compared to actual heat release rates for typical furnishings, as determined by tests conducted in a calorimeter such as the NIST furniture calorimeter9 or by Underwriters Laboratories, Inc. (UL) Subject 1056, Outline of Investigation for Upholstered Furniture. Figures 13.8.2 and 13.8.3 are idealized curves de-

3000 2666 2333 Rate of energy release (kW) 2000 1666 1333 1000 666 333 0 Large chair (300 kW) Small chair (250 kW) 0 200 400 600 800 Time (s) 1000 1200 1400 Plywood wardrobe (2000 kW)

FIGURE 13.8.2 Furniture

Heat Release Rates for Miscellaneous

3000

MO4 Latex (2720 kW)

2666

6000 Heat release rate (Btu/s) 5000 4000 3000 2000 1000 0

Ultra fast 2 Hospice fire 1

Fast 2 Rate of energy release (kW)

2333 2000 1666 1333 1000 666 333 MO3 Cotton (FR) 30 kW 0 0 200 400 600 800 Time (s) 1000 1200 1400 MO6 Cotton/ polyester (970 kW) MO2 PU (1620 kW)

Medium 2 A

Slow 2

30

90 150 210 270 330 390 450 510 570 630 Time from ignition (s)

1 From NFPA study of the hospice fire, Southfield, Michigan, December 1985 and CFR/NBS computer fire model analysis 2 From NFPA 72 , National Fire Alarm Code A Room flashover

FIGURE 13.8.1 Comparison of the Hospice Fire to NFPA 72, National Fire Alarm Code Growth Curves

FIGURE 13.8.3

Heat Release Rates for Beds

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veloped by NIST that illustrate the rate of heat release for typical furnishings as a function of time. Such information can be used to establish the probability of flashover; it also allows estimation of the time required to reach critical fire size.

those with a minimum critical radiant flux of 0.45 W/cm2. Where automatic sprinklers are provided, interior floor finishes need not be regulated beyond the federal flammability standard.

Interior Finish
A successful fire protection strategy requires fires to remain small. Any large fire in a confined space creates a potentially lethal atmosphere. A fires initial growth may be affected significantly by the interior finish of walls, ceilings, and floors. Interior finishes, therefore, deserve special attention. Combustible wall and ceiling finishes can act as a fuse, causing a fire to spread to objects remote from the fire origin. Wall and ceiling finishes also provide a large continuous surface over which fire may spread. Thus, an interior finish may, by releasing energy, cause a fire that would otherwise have remained small to become large. The relative hazard of an interior finish is usually determined by a test conducted in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, commonly called the tunnel test. Interior finish on walls and ceilings within the means of egress and any room should be limited to Class A materials, which have a flame-spread rating of 25 or less. Class B materials, or those with a flame-spread rating of 25 to 75, are considered tolerable, but they should be limited to small rooms. Full-scale experiments show that automatic sprinklers can limit fire growth in rooms with Class C wall and Class D ceiling finishes.2,5 Accordingly, in buildings with automatic sprinkler protection, it has been judged acceptable practice to allow the use of materials having higher flame spread classifications than would otherwise be permitted. For example, Class B materials are sometimes used where Class A is normally specified, and Class C materials where Class B is normally required. In new healthcare facilities, higher flame spread classifications are permitted based on the mandatory requirement for sprinklers. Further, it has been shown that the performance of interior finishes also is related to location.10 Finishes on the upper portions of walls and ceilings contribute more significantly to flame propagation than finishes on the floor or on the lower half of a wall. Therefore, where finishes are limited to the lower half of a wall and are less than 4 ft (1.2 m) above floor level, materials having a higher flame-spread rating than would otherwise be allowed might be used without significantly affecting fire growth. For example, where Class A materials are judged necessary, a Class B material might be allowed on the lower portion of a wall. In the past, floor finish materials were excluded from requirements for interior finishes, based on favorable experience and the assumption that limited exposure exists at the floor level during an actual fire. However, a fire on January 9, 1970, in the Harmer House Convalescent Home in Marietta, Ohio, significantly changed this attitude.11 Thirty-two persons died in this fire. Carpeting with foam-rubber backing was judged to have played a significant role. Interior floor finishes in the corridors of nonsprinklered healthcare facilities should be limited to Class A materials or

BUILDING CONSTRUCTION
Because occupants of healthcare facilities must be defended in place, construction is an important factor, especially in multistory buildings. Buildings preferably should be constructed of noncombustible materials that resist the effects of fire and maintain structural integrity. Buildings of two or more stories should be constructed of noncombustible materials, with major structural members having at least a 2-hr fire resistance. Materials that either burn or support combustion, although less desirable, are considered acceptable if special precautions are taken. An automatic sprinkler system is an essential part of the total fire defense system for combusitble buildings. Any evaluation of building materials should include consideration of their smoke-generating capabilities. In addition, plastic construction materials, which are becoming more common, are sometimes capable of generating large quantities of smoke.

Subdivision of Building Spaces

Mixed and Separated Occupancies. There are basically two ways to handle multiple occupancies in a building that houses a healthcare facility and other uses. One alternative is to separate the different occupancies. The second alternative is to treat the entire facility as a mixed occupancy and comply with the provisions that are the most stringent of the occupancies involved. The mixed occupancy provision in NFPA 101 states that whenever two or more occupancies are so intermingled that separate safeguards cannot be provided, the area must be treated as a mixed occupancy and comply with the more or most stringent requirements of the occupancies involved. When using the mixed occupancy design alternative, there are no specific firerated separation requirements. Fire-rated separation requirements, however, do apply in addition to other restrictions when adjacent occupancies are separated from healthcare occupancies. The healthcare occupancy chapters and the ambulatory healthcare occupancy chapters stipulate the fire resistance separation requirements (2 and 1 hr, respectively) and other provisions when the healthcare facility is intended to be separated from adjacent occupancies. Figure 13.8.4 shows healthcare and other occupancy areas intermingled without fire separations as a mixed occupancy facility. Figure 13.8.5 shows a healthcare occupancy (hospital) separated from an adjacent business occupancy and ambulatory healthcare occupancy. In this case, 2-hr fire resistive separations are used to qualify the hospital, business, and ambulatory healthcare areas as separate occupancies. Separation of Patient Sleeping Rooms. Because it may not be possible to remove occupants during a fire, sleeping rooms other than the room of fire origin sometimes must serve as

1384 SECTION 13 I Systems Approaches to Property Classes

Egress is shared

Ambulatory healthcare occupancy

Industrial occupancy

Healthcare Healthcare occupancy Outpatient clinic Laboratory Maint.

Egress is shared Cafeteria Auditorium Office

Healthcare Office

Healthcare

Healthcare occupancy

Egress is shared

Assembly occupancy

Business occupancy

FIGURE 13.8.4

Multiple Occupancy Area

Healthcare occupancy

Business occupancy 2-hr separation Medical office building Hospital Outpatient clinic

Ambulatory healthcare

Horizontal exit

FIGURE 13.8.5

Separated Occupancies

temporary areas of refuge. Therefore, sleeping rooms should be isolated from all other building spaces by fire-rated construction. Partitions should be continuous from the floor slab to the floor or roof above through any concealed spaces, such as those above suspended ceilings. If the building is protected by sprinklers, NFPA 101 allows these walls to be nonrated, provided the walls resist the passage of smoke, and they are permitted to terminate at the ceiling, provided the ceiling resists the passage of smoke (see Figure 13.8.6 for typical floor plan for a healthcare facility). There has been much discussion in the past about the operational considerations versus the fire safety considerations of equipping patient room doors with door closures. Model building codes and NFPA 101 do not require door-closing devices

on patient room doors. The current opinion is that a healthcare facilitys functional needs prevail, and other fire safety and operational features a healthcare facility provides are adequate alternatives to door closures. Any penetration of 1-hr partitions by building service equipment should be protected in order to maintain the 1-hr firerated separation. All spaces around piping and ducts should be sealed tightly with a noncombustible material having adequate fire resistance and capable of retarding the transfer of smoke. Transfer grills should not be used within such doors or partitions. Smoke Barriers. Every floor used by inpatients should be subdivided into at least two compartments by 1-hr partitions

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Hazardous space 1-hr separation using fire doors Sleeping rooms

Smoke barrier or horizontal exit partition continued from outside wall to outside wall through concealed spaces Kitchen

Lounge & dining

Waiting 1-hr partition & space 20-min doors (Nonrated smoke-resistive if building sprinklered)

Nurse station

150 ft max (45.7 m)

FIGURE 13.8.6

Typical Floor Plan for a Healthcare Facility

capable of retarding smoke. A horizontal exit, when constructed to satisfy the additional criteria imposed on construction of smoke barriers, is a desirable alternative to smokestop partition. Smoke barriers and smoke compartments play a very important fire safety role in healthcare facilities. Subdividing each floor minimizes the number of occupants exposed to a single fire. More importantly, the barriers allow for horizontal evacuation of occupants to an area of refuge on the same floor. In a protect-inplace occupancy where evacuation is difficult, having the capability to evacuate horizontally is extremely important. In new healthcare construction, smoke barriers are generally required to subdivide into at least two compartmentsevery story used for inpatient sleeping and treatment and any story in the building, regardless of occupancy, that has an occupant load of greater than 50 people. In existing facilities, subdividing a space with a smoke barrier is required only on stories with patient sleeping areas that can accommodate more than 30 pa-

tients. Several exceptions to the general requirement for smoke barriers in new healthcare construction are found in NFPA 101. For stories that must be subdivided, there are two limitations on how large the smoke compartment formed can be, related to area and travel distance from any point to a door in a smoke barrier. No smoke compartment can exceed 22,500 sq ft (2100 m2) nor can the travel distance from any part of a smoke compartment to the door in a smoke barrier exceed 200 ft (60 m). One exception for existing healthcare occupancies is that the travel distance to reach the smoke barrier door need not be limited where neither the length nor width of the smoke compartment exceeds 150 ft (45 m). Figures 13.8.7 and 13.8.8 illustrate the basic dimensional criterion and features that constitute an appropriate smoke compartment arrangement for new and existing healthcare facilities. In addition to the features shown in Figures 13.8.7 and 13.8.8, the minimum size of an area must be able to accommodate a certain number of people in an emergency based on factors that range from 30 net sq ft (2.8 m2) per patient for hospital and nursing homes to as low as 3 net sq ft (2.8 m2) per person on floors with nonhealthcare spaces.

Protection of Vertical Openings

Fire and fire-produced contaminants tend to spread vertically within a building. Special effort is required to prevent fire on one level from threatening the occupants above; this is especially important in healthcare facilities. All shafts should be provided with fire-rated enclosures. Vertical openings not connecting more than three floors should have a minimum of 1-hr fire resistance rating. Two-hour fire resistance ratings should be provided for vertical openings connecting more than three floors. Openings to shaft wells are limited to those necessary, and these openings must be protected. When designing partitions to enclose vertical shafts, consideration should be given to the varying durability of materials.

Smoke barrier Area 22,500 ft2 (2100 m2)

X

Patient rooms

1-hr rated

200 ft (60 m)

Pair of doors required

20-min door 1-hr rated

Nurses station

20-min door

Wired glass or rated glazing Pair of doors required

20-min door

Patient rooms

1-hr rated

Continuous horizontally and vertically

FIGURE 13.8.7

Smoke Compartment in a New Healthcare Facility

1386 SECTION 13 I Systems Approaches to Property Classes

Area 22,500 ft2 (2100 m2) 150 ft (45 m)

Smoke barrier

Patient rooms

-hr rated

Single door permitted

20-min door

-hr rated 150 ft (45 m)

Nurses station

20-min door Wired glass or rated glazing 20-min door

Patient rooms
X

-hr rated

Continuous horizontally and vertically 150-ft (45-m) maximum dimension OR 200 ft (60 m) travel distance permitted in existing

FIGURE 13.8.8

Smoke Compartment in an Existing Healthcare Facility

In spaces where partitions may be subject to mechanical injury, materials used to provide floor-to-floor separation should be able to resist damage in order to maintain the required fire resistance.

Exit Design
Exits in healthcare facilities should be limited to doors leading directly outside of the building, interior stairs and smokeproof enclosures, ramps, horizontal exits, outside stairs, and exit passageways. Vertical evacuation of occupants within a healthcare facility is, at best, difficult and time consuming. Therefore, horizontal movement of patients is of primary importance. Horizontal passageways and doors opening into corridors and rooms used for sleeping or treatment should be wide enough to allow the horizontal movement of occupants, even those in beds. Relocation of patients is a slow process, even under favorable staff-to-patient ratios. Because of the time required to move patients, exit access routes should be protected against fire effects. Spaces open to the corridor should not be used for patient sleeping or treatment rooms, nor should hazardous contents or activities be permitted within them. Such spaces should be equipped with electrically supervised smoke detectors that, if activated, will sound the building fire alarm. Horizontal Exits. Horizontal exits are common in healthcare facilities. Partitions used as horizontal exits and smoke barriers should provide the fire resistance required for exits and, in ad-

dition, should satisfy the criteria for smoke barriers when appropriate. If possible, door openings should be limited to corridors, lobbies, or public spaces. The most desirable arrangement of mechanical systems is one in which the partitions forming the horizontal exit are not penetrated. If penetration by utilities or piping occurs, the space around the piping should be filled tightly with noncombustible materials and maintain the barriers required fire resistance. If ducts penetrate partitions intended to be smoke barriers, combination fire/smoke dampers that close if smoke detectors within the duct activate should be provided. Two-hour fire barrier walls must be used to create horizontal exits. They do not need to be structurally freestanding, but they must be supported by 2-hr construction and must penetrate any ceiling and continue to the floor or roof deck above. NFPA 101 requires vertical continuity of these walls in that they must be continuous to the ground. The fire barrier is allowed to be omitted on any story below, provided the floor below the lowest level on which the barrier exists and all supporting members are of a 2-hr fire resistive construction and with exit stairs leading to the outside of the building. Figure 13.8.9 illustrates the vertical continuity of walls forming horizontal exits. Because a horizontal exit implies that occupants will be transferred from one side of a partition to the other (horizontal evacuation), adequate space must be available to house occupants after movement. In hospitals, at least 30 net ft2 (2.79 m2) per patient should be available on each side of the horizontal exit, allowing for the total number of patients in adjoining compartments.

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7 6 5 4 3 2 2-hr rated Horizontal exits

Limits on travel distance reflect anticipated slow movement. Travel distance normally should not exceed the following: 1. One hundred feet (30 m) between an exit and any room door intended for use as an exit access 2. One hundred and fifty feet (46 m) between an exit and any point in a room 3. Fifty feet (15 m) between any point in a sleeping room or suite of sleeping rooms and the exit access door of that room Increases in corridor travel distance are permitted in sprinklered buildings. Because smoke barriers and areas of refuge play such an important role in fire safety, travel distances to smoke barriers is also restricted in NFPA 101. Travel distance from any point on a floor to reach a door in a smoke barrier is limited to 200 ft (61 m). In addition, facilities should be arranged to limit travel in the direction of the fire to less than 30 ft (9 m). Elevators are not usually counted as required exits because they possess numerous shortcomings that may prevent their use during a fire. In the cases of critically ill patients, patients in body casts or balkan frames, and others who would be difficult to move, however, elevators provide the only practical evacuation method from upper stories of the facility. If separate banks of elevators are located in separate smoke compartments, and if the staff are well trained, it may be possible to devise a plan in which using elevators during fires is safe.

1
2-hr rated support for 2-hr wall
Direct to outside

FIGURE 13.8.9 Floors

Building with Horizontal Exits on Some

Interior Stairs. Exit stairs should be designed to satisfy the criteria for interior stairs. Stairs should be enclosed with fireresistive materials, with stair openings limited to those necessary for access and discharge purposes. Stairs must be properly protected from the effects of fire.

Exit Features
Life safety from fire in healthcare facilities relies on a defendin-place principle. Horizontal exits or smoke barriers are required to subdivide each story of a healthcare facility to provide an area of refuge on each floor. The original concept for the design of exits for healthcare facilities was derived from studies conducted in the early part of this century. A practice evolved of using exit stair enclosures as areas of refuge. Exit capacity for healthcare facilities was set conservatively to offset slow travel rates and to create space within exit enclosures for storing patients on litters and in wheelchairs. Means for horizontal evacuation are provided for each story, using either a smoke barrier or a horizontal exit. A barrier subdivides each story to provide an area of refuge for patients without traversing stairs. Furthermore, it is commonindeed, it is required since the 1994 edition of NFPA 101to install automatic sprinklers throughout all new healthcare facilities. Automatic sprinklers limit fire size and complement the defendin-place strategy currently in use. Exit capacity in nonsprinklered healthcare facilities is set at 0.6 in. (15.24 mm) per person for travel over stairs, whereas the capacity through doors and level passageways is calculated at 0.5 in. (12.7 mm) per person. Where automatic sprinklers are provided throughout a building, exit capacity is increased to 0.3 in. (7.62 mm) per person for travel over stairs and 0.2 in. (5.08 mm) per person for travel over level passageways. Capacity is calculated using a flow rate principle. Flow rates assumed are for able-bodied persons because it is presumed that evacuation over stairs will involve only staff, visitors, and ambulatory patients. Nonambulatory occupants are expected to remain in the building under the defend-in-place concept, with those patients on the floor of fire origin being moved horizontally to an area of refuge.

Exit Marking and Exit Illumination

Readily visible signs should mark all exits. Where access to exits is not immediately visible, access routes also should be marked. The entire means of egress must be continuously illuminated whenever the building is occupied. In some cases, normal street lighting is adequate for illumination of exit discharge. However, consideration should be given to the conditions that would result from a power failure. Emergency power is also required to illuminate the means of egress and exit marking. In hospitals, this power should be supplied by the life safety branch of the hospitals essential electrical system. Luminescent, fluorescent, or reflective material should not be substituted for required lighting. Emergency power supplies should maintain illumination automatically in the event of a power failure, without any appreciable interruption during the changeover from normal to emergency power. Where a generator is provided, the delay should not be more than 10 s, per NFPA 99, Standard for Health Care Facilities. Where emergency power is supplied by a central system with an engine-driven generator, the design should minimize the possibility of any single emergency simultaneously interrupting both normal and emergency power supplies. The switch(es) that transfers power from normal to emergency circuits is one place where normal and emergency circuits are required to merge. If this switch(es) is exposed to fire, it could simultaneously interrupt power to both normal and emergency circuits. The transfer switch and other electrical distribution

1388 SECTION 13 I Systems Approaches to Property Classes

panels and switch gear should be separated from the generator, as well as from the remainder of the building.

Fire Alarms
Every building should be equipped with an electrically supervised, manually operated, fire alarm system. When actuated, the system should sound alarms that can be heard above ambient noise levels throughout the facility. Usable alarm indicating devices are permitted in critical areas in lieu of audible alarm devices. The fire alarm should also transmit automatically to the fire department. Any fire detection or fire suppression system that activates should automatically activate the building alarm system. Alarm systems, including detection devices, should be provided with an emergency power supply and designed according to NFPA 72. Any alarm that is activated should provide automatically, without delay, a general alarm. Presignal systems are not considered suitable for healthcare occupancies. Zoned systems with a coded signal have certain desirable characteristics and should be considered for use.

switches with a local alarm at a constantly attended location when the valve is closed. If pressure tanks are the primary source of water, air pressure, water level, and temperature should be supervised. If fire pumps are provided, electrical supervision should monitor the fire pump in accordance with NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection. Portable fire extinguishers should be placed in all buildings, as they may provide an opportunity to control a fire during its early stages. In all cases, however, the fire department should be notified before or at the same time that occupants are attempting to fight the fire. Delayed alarms have allowed fires to grow to large scale and, in turn, threaten occupants before fire department notification and arrival.

Smoke Control
Although operable windows were required in every patient sleeping room for many years, NFPA 101 no longer requires them. Outside windows are required but need not be operable. Windows in atrium walls are considered outside windows in healthcare facilities. Special forced-air systems or, in some cases, the adaptation of conventional building air-handling systems can permit venting of products of combustion early in the fire. Such systems may also make it possible to create a pressure difference across physical barriers, such as floors or partitions, and prevent smoke transfer. The effectiveness of fire partitions often improves significantly by the use of such systems. Where adaptation of the building air-handling system is contemplated for smoke removal, their design should be as NFPA 92A, Recommended Practice for Smoke-Control Systems, suggests. Consideration should be given to alternative power supplies and electrical supervision of critical system components.

FIRE SUPPRESSION EQUIPMENT

A proven effective, practical, and reliable approach to life safety in healthcare facilities is to use automatic fire suppressionin particular, automatic sprinkler systems. Although persons in the area of origin may still be seriously threatened, those in adjoining spacesand, in a number of cases, in the same roomare protected.2,5,6,12 NFPA 101 requires all new healthcare facilities to be protected by automatic sprinklers. The ability of automatic sprinklers to provide a survivable environment for building occupants has been debated at length. Full-scale tests have shown that standard sprinklers can extinguish many fires while maintaining a survivable atmosphere outside the room of fire origin.2,5 In addition, sprinklers have been shown to be effective in limiting carbon monoxide to nonlethal levels outside the room. Tests have also shown that privacy curtains may interfere with sprinkler discharge.13 To obtain full sprinkler effectiveness, the influence of any building design feature or furnishing that would impair sprinkler discharge should be evaluated carefully. The quick-response or fast-response sprinkler has been shown in most instances to maintain a survivable atmosphere within the room of fire origin. Full-scale tests at NIST have documented this performance.13 Where fire defenses are based on automatic sprinkler systems, fast-response sprinklers should be considered for the entire building. At a minimum, fast-response sprinklers should be used throughout compartments having sleeping rooms. This is now required for new healthcare facilities by NFPA 101. Automatic sprinklers should adhere to NFPA 13, Standard for the Installation of Sprinkler Systems. Sprinklers operation should sound the building fire alarm automatically. The sprinkler system and components should be supervised electrically to ensure reliable operation; this should include valve tamper

PROTECTION OF HAZARDOUS AREAS

Areas with contents more hazardous than those normally found in healthcare facilities should be arranged to minimize occupant exposure if a fire occurs. NFPA 101 addresses hazardous areas in general and also addresses hazardous areas in the specific occupancy chapters. The general provisions require one of the following: 1. Enclose the hazardous area with a fire barrier having a 1-hr fire resistance rating and without windows 2. Protect the area with an automatic extinguishing system 3. Apply the protection of both (1) and (2) where the hazard is severe or where otherwise specified by the occupancy chapters When the 1-hr enclosure is used, the doors must be -hr fire rated, self-closing, and positive-latching doors. Typically, in new construction and in any healthcare occupancy, when a hazardous area is sprinkler protected without having a fire resistance rated enclosure, the area must be protected with at least a smoke-resisting enclosure equipped with smoke-resisting self-

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or automatic-closing doors. In healthcare facilities, corridor doors are normally required to latch. Doors in hazardous areas are typically required to be self- or automatic-closing doors and self-latching. The healthcare occupancy chapters of NFPA 101 detail the specific areas that must be addressed as hazardous areas; however, the listed areas are not intended to be all-inclusive, and the general provisions must be met if an area poses unusual fire hazards in the healthcare facility. Table 13.8.7 summarizes the specific areas that must be addressed as hazardous areas in both new and existing healthcare facilities. In addition to the specific areas listed in Table 13.8.7, there are provisions related to other hazardous areas, including gift shops, laundry and trash chutes, cooking facilities, and laboratories. Gift shops must be protected as hazardous areas when they are used for storing or displaying combustibles in quantities considered hazardous. NFPA 101 provides no guidance on this; however, the typical gift shop would usually be allowed to comply with the special provisions for gift shops. Trash chutes and linen chutes can pose significant fire risks for healthcare occupancies. NFPA 101 requires these areas to comply with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment. NFPA 101 requires laboratories, anesthetizing locations, and medical gas systems to comply with the provisions of NFPA 99, which relate to the protection of hazardous areas. New heliports must comply with NFPA 418, Standard for Heliports. Cooking facilities are required to be protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

an important factor in fire, due regard should be given the design of rubbish and linen chutes, including pneumatic systems. Portable heating devices are unsafe in patient-occupied portions of healthcare facilities. All heating devices should be designed and installed to prevent ignition of combustible materials. Approved suspended unit heaters may be used, except in means of egress and patient sleeping areas, if they are high enough to be out of the reach of persons using the area. Air for combustion and ventilation in boilers, incinerators, or heater rooms should be taken directly from, and discharged directly to, the outside of the buildings.

OPERATING FEATURES
Smokers cause many fires in healthcare facilities. Adoption and enforcement of suitable smoking regulations is essential.7 Smoking should be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored. Such areas should be posted with suitable signs. Smoking by patients who are under sedation or who are not considered responsible should be prohibited. Smoking should be permitted in a sleeping room only when authorized by medical staff and then only under direct staff supervision. Metal containers with self-closing covers should be available for disposal of smoking materials in all areas where smoking is allowed. Most hospitals and many nursing homes have established no-smoking policies. JCAHO requires hospitals to be smoke free. Nursing homes are becoming smoke free on a voluntary basis. These are very positive steps in improving the level of fire safety in healthcare facilities. Visitors sometimes give patients smoking materials without the staffs knowledge. Health care facilities need to address this serious issue. In 1989, 12 residents died in a Norfolk, Virginia, nursing home fire attributed to a visitor giving a resident smoking materials.

Building Service Equipment

Building service equipment should be installed and maintained in accordance with appropriate NFPA standards. Special consideration should be given to the design and installation of heating and air conditioning systems. Because rubbish chutes can be

TABLE 13.8.7

Typical Hazardous Areas

New Existing Smoke-Resisting Enclosure with Self-Closing Doors 1-hr Enclosure or Sprinklers Boiler rooms Fuel-fired heater rooms Soiled linen room Rooms > 50 sq ft (4.6 m2) designated by AHJ Laundries > 100 sq ft (9.3 m2) Repair shops Paint shops Trash collection rooms Laboratoriesa (without severe hazard)

1-hr Enclosure Boiler rooms Fuel-fired heater rooms Soiled linen rooms Storage rooms > 100 sq ft (9.3 m2) Laundries > 100 sq ft (9.3 m2) Maintenance shops Paint shops Trash collection rooms Laboratoriesa (with severe hazard)

Storage Rooms > 50 sq ft (4.6 m2) but < 100 sq ft (9.3 m2)

Laboratoriesa (without severe hazard)

AHJ = Authorities having jurisdiction. a Laboratories considered severe hazard shall comply with NFPA 99. Source: Life Safety Code Seminar Workbook, 1997, p. 324.

1390 SECTION 13 I Systems Approaches to Property Classes

Window draperies and curtains should be made of noncombustible material or material that has been rendered and maintained flame retardant. These window hangings should be capable of passing both the large- and small-scale tests required by NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. Furnishings, decorations, and other objects should not obstruct exits or exit access routes. Combustible decorations should be prohibited. Exits and mechanical devices provided to control or limit fire should be maintained to ensure reliable operation. Inspections and tests should be performed, as required, to verify satisfactory performance. In facilities with locked exits, adequate staff should always be present to release occupants and direct them away from the fire area to a place of safety during an emergency. Care should be exercised during construction and repair operations to ensure that such activities do not reduce life safety. Adequate preventive maintenance for mechanical systems, including tests and periodic inspections, are necessary to ensure their reliability.

Evacuation practices for all areas Preparation of building spaces for evacuation Fire extinguishment During drills, emphasis should be on immediate notification of the fire department; many fires have spread because of delayed alarms.

EQUIVALENCY METHODOLOGIES
NFPA 101 contains the fundamental statement of the equivalency concept, which provides for the use of alternatives to the methods, materials, devices, systems, and so on, that are prescribed and/or specifically detailed by NFPA 101. Key to the concept of equivalency is the submission of technical documentation acceptable to the authority having jurisdiction. One method of providing technical documentation for healthcare facilities is to appropriately apply and utilize the Fire Safety Evaluation System for Health Care Occupancies (FSES), which provides a formalized equivalency methodology specific to healthcare occupancies. The documentation and procedure for the use of this fire safety evaluation system is found in NFPA 101A, Guide on Alternative Approaches to Life Safety. The FSES for Health Care Occupancies has, since the 1981 edition of NFPA 101, provided a basis for developing alternatives that achieve a level of safety equivalent to that mandated by the Life Safety Code. The FSES was developed to provide a rational basis for achieving the level of safety intended by the Code without necessarily meeting all of its prescriptive requirements. This can be especially important for existing buildings in which physical conditions may not allow strict compliance or where retroactive compliance may present an economic hardship. The FSES involves the evaluation and comparison of the risk factors and safety features present or proposed for a healthcare occupancy. The FSES methodology for healthcare occupancies is based on the evaluation of individual zones, which are generally the spaces separated by floors, horizontal exit barriers, or smoke barriers. The risks of a zone consider the number of people affected by a given fire, the density of the people in the zone, the mobility of the patients, the age of patients, the location of the zone, and the ratio of patients to staff in the given zone. Table 13.8.8 shows the risk parameters and risk factor values that apply when evaluating a zone. In addition to the risk aspects of the FSES, each zone must consider the ability of the building and its fire protection features to provide measures of safety commensurate with the risk. Safety parameters that are evaluated include building construction fire resistance, interior finish, corridor partitions/walls, corridor doors, zone dimensions, vertical openings, hazardous areas, smoke control, egress routes, fire alarms, fire detection, and automatic sprinklers. Redundancy of the safety features is an important aspect of the FSES. By evaluating the redundancy of safety features, the methodology intends to ensure that the failure of a single protection feature or device will not result in major failure of the entire system. The approach is quantitative in that the FSES awards positive point values for strong life safety and fire protection fea-

EMERGENCY PLANNING
In no occupancy is staff training and emergency planning more important than a protect-in-place occupancy housing a significant number of occupants incapable of self-preservation. Every healthcare facility must have a fire and evacuation plan, including a disaster plan, with which all personnel must be familiar. NFPA 99 provides guidance for both internal and external disasters that affect healthcare facilities. In addition, personnel should be trained to use fire extinguishers and hose cabinet lines if provided. They must also know how to sound an alarm, move or evacuate patients, and contain the fire. Each facility should have a safety officer whose primary responsibility is to recognize hazards, act as liaison with the fire service, and arrange for training personnel. While training healthcare personnel is straightforward and can be accomplished on the job, orienting members of the fire service to healthcare facility problems is more difficult. Copies of the fire and evacuation plan should be available to all personnel. The plan should contain specific instructions for keythat is, supervisorypersonnel if there is a fire. A copy of the plan also should be posted for reference. All employees should be periodically trained to ensure readiness. Emergency drills should include transmission of a fire alarm signal and simulation of emergency conditions insofar as possible without jeopardizing occupants. Drills should be conducted on each shift at least quarterly, with at least 12 drills held every year. The drills should be varied to test the alertness of all shifts and, if possible, should be unannounced. Use of the building alarm during drills also verifies its normal operation. The fire and evacuation plan should include the following fundamentals: Training personnel to use the alarm and alarm equipment Transmission of alarm to the fire department Details of the fire location

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TABLE 13.8.8

Occupancy Risk Parameter Factors

Risk Factor Values Mobility Status Risk Factor Mobile 1.0 Limited Mobility 1.6 Not Mobile 3.2 Not Movable 4.5

Risk Parameters 1. Patient Mobility (M)

2. Patient Density (D)

No. of Patients Risk Factor

15 1.0

610 1.2

1130 1.5

>30 2.0

3. Zone Location (L)

Floor Risk Factor

1st 1.1

2nd or 3rd 1.2

4th to 6th 1.4

7th and Above 1.6

Basements 1.6

4. Ratio of Patients to Attendants (T)

Patients Attendant Risk Factor

12 1 1.0

35 1 1.1

610 1 1.2

>10 1 1.5

One or Morea None 4.0

5. Patient Average Age (A)

Age Risk Factor

Under 65 Years and Over l Year 1.0

65 Years and Over 1 Year and Younger 1.2

A risk factor of 4.0 is charged to any zone that houses patients without any staff in immediate attendance.

tures and negative point values for lesser conditions. With appropriated selection of alternative features a number of both positive and negative factors can be balanced in a manner that results in establishing a level of life safety equivalent to NFPA 101 without complying with all of its prescribed requirements. The FSES methodology has a long and proven track record, but it is not the only approach available for establishing equivalency. NFPA 101 formally recognizes performance-based options for the design and analysis of alternatives to the prescribed requirements of the Code. Additional discussion of the performance-based option can be found in Section 3, Chapter 13, Performance-Based Codes and Standards for Fire Safety.

a greater risk than medical office buildings (business occupancy) that provide for routine doctor visits. The definition of an ambulatory healthcare occupancy has three key elements. 1. An ambulatory healthcare occupancy is a building or portion of a building used to provide services or treatment simultaneously to four or more patients. 2. The services or treatment provided is done solely on an outpatient basis and renders the patients incapable of taking action for self-preservation under emergency conditions with out the assistance of others. 3. Anesthesia is provided solely on an outpatient basis and renders the patients incapable of taking action for selfpreservation under emergency conditions with out the assistance of others. The distinguishing features of an ambulatory healthcare occupancy are that 24-hr sleeping accommodations are not provided and services are rendered solely on an outpatient basis. This effectively means that patients walk in and walk out of the facility but may be subject to treatment or anesthesia that temporarily renders them incapable of self-preservation, including postoperative recovery in a bed.

AMBULATORY HEALTHCARE
Prior to the 2000 edition of NFPA 101, ambulatory healthcare occupancies were addressed within the healthcare occupancy chapters. Now, NFPA 101 provides focus on ambulatory healthcare with new chapters dedicated specifically to addressing requirements for new and existing ambulatory healthcare occupancies. The healthcare facility categoryambulatory healthcareintends to fulfill the needs of facilities that do not pose the risks of 24-hr healthcare facilities such as hospitals, but do pose

1392 SECTION 13 I Systems Approaches to Property Classes

The life safety and fire protection features specified in NFPA 101 for ambulatory healthcare occupancies are a blend of those used for both healthcare occupancies and business occupancies. In fact, many of the provisions for ambulatory healthcare facilities are simply addressed by references to the provisions for business occupancies. Construction type requirements are less than those required for healthcare buildings but more restrictive than allowed for business occupancies. Several egress requirements are more restrictive than those permitted for business occupancies. Also, there are specific provisions for mixed occupancies, smoke compartments, and fire alarm features that will affect the design of an ambulatory healthcare occupancy.

10. Christian, W. J., and Waterman, T. E., Flame Spread in Corridors: Effects of Location and Area of Wall Finish, Fire Journal, Vol. 65, No. 4, 1971. 11. Sears, A. B., Jr., Nursing Home Fire, Marietta, OH, Fire Journal, Vol. 64, No. 3, 1970. 12. Boettcher, E. N., M.D. Hospital Fire Defense: People and Sprinklers, Fire Journal, Vol. 61, No. 4, 1967, pp. 9396. 13. Notarianni, K. A., Five Small Flaming Fire Tests in a Simulated Hospital Patient Room Protected by Automatic Fire Sprinklers, Report of Test FR-3982, Oct. 31, 1990, National Institute of Standards and Technology, Gaithersburg, MD.

Reference
UL Subject 1056, Outline of Investigation for Upholstered Furniture, Underwriters Laboratories Inc., Northbrook, IL.

SUMMARY
Total building fire protection for life safety is more necessary in healthcare facilities than in other occupancies because of the nature of the occupants. A significant percentage of occupants in hospitals and nursing homes are incapable of self-evacuation or are ambulatory but incapable of perceiving a fire threat and choosing a rational response. Therefore, fire protection is based on a defend-in-place principle and cannot depend on any one safeguard. As a result, healthcare facility design and operation must incorporate methods by which a fire can be detected early, contained, and fought rapidly and successfully. Fire safety requirements include fire-resistive construction, compartmentation, fire-alerting facilities, and control of smoke movement. In addition, it is critical that every healthcare facility have a fire and evacuation plan, including a disaster plan, with which all personnel are familiar. Personnel should be trained in emergency procedures, including how to sound an alarm, move or evacuate patients, and contain the fire. Emergency drills should be conducted on each shift at least quarterly, with at least 12 drills held every year.

NFPA Codes, Standards, and Recommended Practices

Reference to the following NFPA codes, standards, and recommended practices will provide further information on health care facilities discussed in this chapter. (See the latest version of The NFPA Catalog for availability of current editions of the following documents.) NFPA 13, Standard for the Installation of Sprinkler Systems NFPA 20, Standard for Installation of Stationary Pumps for Fire Protection NFPA 30, Flammable and Combustible Liquids Code NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites NFPA 72, National Fire Alarm Code NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems NFPA 92A, Recommended Practice for Smoke-Control Systems NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations NFPA 99, Standard for Health Care Facilities NFPA 101, Life Safety Code NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films

Additional Readings

BIBLIOGRAPHY
References Cited
1. Building Materials and Structures, Report BMS 92, National Bureau of Standards, Washington, DC, 1942. 2. Full-Scale Fire Tests in a Nursing Home Patient Room, Report 7463, U.S. Department of Health, Education and Welfare, HEW Contract HSA 105-74-116. Prepared by American Health Care Association, 1975. 3. Best, R., The Wincrest Nursing Home Fire, Fire Journal, Vol. 70, No. 5, 1976. 4. Best, R., The Cermak House Fire, Fire Journal, Vol. 70, No. 5, 1976. 5. ONeill, J. G., et al., Full-Scale Fire Tests with Automatic Sprinklers in a Patient Room, Phase II, NBSIR 80-2097, National Bureau of Standards, Gaithersburg, MD, 1980. 6. Hall, J. R., Jr., The Elderly, the Sick, and Health Care Facilities, Fire Journal, Vol. 84, No. 4, 1990. 7. NFPA Fire Analysis Division, Fatal Fire Risks and Hazards in Health Care Facilities, Fire Journal, Vol. 81, No. 5, 1987. 8. Babrauskas, V., Estimating Room Flashover Potential, Fire Technology, May, 1980. 9. Babrauskas, V., et al., Upholstered Furniture Heat Release Rates Measured with a Furniture Calorimeter, NBSIR 82-2604, National Bureau of Standards, Washington, DC, 1982.

Abrahams, J., More Changes Afoot for Fire Safety in Hospitals and Care Premises, Fire, Vol. 84, No. 1043, 1992, pp. 2324. Ainley, J., and Charters, D., Fire Precautions in New Hospitals, NHS Estates, UK, ISBN 0-9527398-3-6; Institution of Fire Engineers, University of Sunderland, Fire Research Station, CIB W14, Tyne and Wear Metropolitan Fire Brigade, Fire Safety by Design, Conference Proceedings, Vol. 3, Research Papers, July 1012, 1995, UK, 1995, pp. 221233. Architects View of Fire Protection for Old and New Hospital Buildings, Fire, Vol. 84, No. 1043, 1992, p. 27. Bartlett, G., Achieving Hospital Safety Through Fire Engineering, Fire Prevention, No. 276, Jan./Feb. 1995, pp. 2932. Bartlett, G., Hospital Fire Officers Must Cultivate a Co-Ordinating Role, Fire, Vol. 87, No. 1077, 1995, pp. 1516. Bentley, R., Hospital Fire Safety Hampered by Plethora of Aging Buildings, Fire, Vol. 82, No. 1018, 1990, pp. 4142. Bentley, R., Human Aspects in Fire SafetyThe Hospital Fire Officiers View, Fire Prevention, No. 246, Jan./Feb. 1992, pp. 2022. Cable, E. A., Analysis of Delay in Staff Response to Fire Alarm Signals in Health Care Occupancies, Worcester Polytechnic Inst., MA, Thesis, Jan. 1993. Cass, P., Hospital Managements Need Guidance From Specialist Fire Safety Advisers, Fire, Vol. 84, No. 1043, 1992, p. 34. Chandler, S. E., Trends in Hospital Fires, Fire Prevention, No. 246, Jan./Feb. 1992, pp. 1415.

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