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Three life safety issues to watch for


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While they may look like common, innocuous problems to you, The Joint Commission life safety specialists may take a decidedly stricter view.

Corridor clutter, damaged fire-rated doors, and unsealed penetrations in rated barriers are three pieces of low-hanging fruit that life safety specialists will target-so it's worth educating all of your staff members to be on the lookout for these problems. The risk is real: In 2008, two fire-safety-related requirements made The Joint Commission's top 10 list of cited standards in accredited hospitals.

Remember, life safety specialists generally have backgrounds as facilities directors in hospitals, so they are attuned to this trio of fire protection problems:

Items that obstruct egress corridors: Most wheeled carts and equipment cannot remain parked in a corridor unless a staff member is actively using the item. For example, an environmental services worker can leave a housekeeping cart outside a patient room while he or she services the room.

"If a corridor looks cluttered, it probably is," said George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, who spoke at the American Society for Healthcare Engineering's annual conference in Anaheim, CA, this month.

Wheeled items in use by staff members can be left unattended in egress corridors for up to 30 minutes. Items left unattended, such as a dietary cart parked on the side of a corridor overnight, could result in citations.

Two important exceptions to note, as explained by Mills:

  • Crash carts can always remain in corridors so that staff members can quickly get to them in an emergency, with the understanding that if an alarm goes off or an evacuation is necessary, someone must move the crash carts out of the corridors
  • Infection control isolation carts can remain in corridors indefinitely as long as they are outside an active isolation patient's room (an important point to remember with pandemic flu planning)


Fire-rated doors with visible damage: It's not hard for a fire-rated door to get dented or knocked out of alignment by gurneys and other equipment hitting them each day.

However, even minor damage to these doors could void their technical rating, which then calls into question the doors' effectiveness at protecting people.

The whole door assembly (i.e., door and frame) is designed specifically to resist fire, safety consultant Steven MacArthur recently wrote on his blog, Mac's Safety Space.  MacArthur works for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

"If there's anything at all deficient about the door, you can't be assured it will do what it needs to in the event of a fire, which is to provide a sufficient barrier between flames and occupants," he wrote.

Improperly sealed penetrations poking through barriers: Outside contractors and in-house IT teams are constantly running pipes, ducts, and cables through rated smoke and fire barriers. Those holes should be sealed with an approved firestopping product, but that doesn't always happen, Mills said.

He has been warning hospital safety professionals to keep an eye out for penetration problems. These deficiencies not only risk the safety of patients, visitors, and employees during a fire, but also raise the issue of whether hospital leaders are aware of the work being done to their buildings' fire protection features, Mills said.