This post was published in Doors & Hardware

Past fires in hospitals and nursing homes – and the resulting fatalities – have shaped the codes that we use today.  While the code requirements for health care facilities go far beyond the doors, frames, and hardware, there are some important considerations for door openings to ensure that they provide the necessary fire protection, egress, and accessibility for residents and staff. Although today’s codes do not typically require corridor doors such as those leading to patient room doors to be fire door assemblies, these doors provide a critical layer of protection for patients.

NFPA 101 – The Life Safety Code

Corridor doors leading to patient rooms are specifically addressed by both NFPA 101 – The Life Safety Code, and the International Building Code. These doors play a critical role in the protection of patients in hospitals and nursing homes.

Although NFPA 101 – Life Safety Code states that most corridor doors in a health care facility, including patient room doors, are not required to comply with NFPA 80 – Standard for Fire Doors and Other Opening Protectives, the code does include some requirements designed to help keep patients safe. Doors must be constructed to resist the passage of smoke, and the clearance between the bottom of the door and the floor covering must be no more than 1 inch.* For existing facilities, either 1 ¾-inch solid bonded-core wood doors, or materials that resist fire for at least 20 minutes, are required.

Positive latching hardware is mandated by the code for corridor doors whether they are fire-rated or not, so doors are self-latching when they are closed and will remain latched against the pressure created during a fire. Pairs of doors with an inactive leaf are required to have automatic flush bolts. Louvers, also called transfer grilles, are not allowed in these doors. Protection plates are permitted, whether factory or field-applied, with no limit in size and no requirement for a label. Annex A of NFPA 101 states that gasketing should not be necessary in order to limit the passage of smoke to an acceptable level, as long as the door is relatively tight-fitting.

Roller latches – friction bolts designed to hold the door in the closed position, are not allowed by NFPA 101 for most patient room doors in new health care occupancies, except in acute psychiatric settings where the clinical needs of patients require protective measures for their safety. In this application, roller latches must keep the door closed if a force of 5 lbf is applied at the latch edge of the door.

Doors in existing facilities are required to have a means of keeping a door closed against a 5-lbf force, and the method of keeping the door closed must be acceptable to the AHJ. NFPA 101 allows roller latches to be used in existing health care occupancies if the building is equipped throughout with an automatic sprinkler system, however, this is not permitted by the Centers for Medicare and Medicaid Services (CMS).  Facilities which receive funding from CMS must have corridor doors with positive-latching hardware – not roller latches.  If a patient room is within a suite, a roller latch may be acceptable as the positive-latching requirement does not typically apply to doors within suites.

Door closers are not required by the current codes for patient room doors that are not fire door assemblies, although fire doors must be self-closing.  Examples of health care corridor doors that would typically be fire rated include doors leading to exit enclosures and hazardous areas; doors in smoke barriers must also be self-closing or automatic-closing. A self-closing door serving a patient room could lead to a delay in discovery of a fire within the room, so automatic smoke detectors that are part of the building’s fire alarm system are recommended for rooms that have door closers. NFPA 101 restricts the use of hold-open devices on patient rooms to those that release when the door is pushed or pulled; doors should not be blocked by furniture, door stops, hooks, or plunger-type hold-opens.

Doors leading to rooms that do not contain flammable or combustible material, such as toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces are not required by NFPA 101 to have doors that are constructed to resist the passage of smoke. These doors do not require positive latching hardware, and ventilating louvers or transfer grilles are allowed.

International Building Code

Chapter 4 of the International Building Code (IBC) contains special requirements for certain occupancy types – for example:  high-rise buildings, motor-vehicle-related occupancies, and special amusement buildings.  The chapter includes a section on Group I-2, which pertains to hospitals, nursing homes, detox facilities, and psychiatric hospitals.  Section 407.3 (2015, 2018, 2021 editions) requires corridor walls in I-2 occupancies to be smoke partitions.  Although section 710 of the IBC details requirements for doors in smoke partitions, section 407.3.1 contains specific requirements for I-2 corridor doors, so those requirements would apply instead of section 710.

Section 407.3.1 states that corridor doors (with the exception of doors required to be rated as an incidental use area and doors that are part of an exit enclosure), are not required to have a fire protection rating. These corridor doors are not required to be self-closing or automatic-closing as the staff is expected to close the doors to patient rooms if there is a fire, or to evacuate patients to an adjacent smoke compartment, but the doors must provide an effective barrier to limit the transfer of smoke. Corridor doors must have positive-latching devices – including constant-latching flush bolts on pairs of doors – and roller latches are not permitted. The IBC Commentary states, “This provision is primarily intended to apply to care recipient sleeping room corridor doors,” however, it may apply to other auxiliary rooms such as exam rooms and support spaces that are not fire rated.

One question that comes up quite often with regard to the IBC requirements for patient rooms is whether gasketing is required in order to limit smoke infiltration. While there is a stated limit for air transmission for fire door assemblies in corridors and smoke barriers, patient room doors do not fall into that category. There is no mention in paragraph 407.3.1 of smoke infiltration or UL 1784 – Air Leakage Tests of Door Assemblies and Other Opening Protectives, so gasketing is not mandated by this section. Prior to the 2015 edition of the IBC Commentary, there was a reference that caused a lot of confusion. When addressing the section on smoke and draft control doors, the Commentary stated: “Section 407.3.1 requires corridor doors in Group I-2 to ‘limit the transfer of smoke’; therefore, those doors must meet this section.”  Although there was no code requirement for patient room doors to meet the limitations for smoke and draft control doors, some AHJs expected patient room doors to comply with the stated limits for air transmission based on the Commentary language. The incorrect statement was removed from the 2015 edition of the Commentary.

Another common question is whether patient room doors are required to be inspected annually, as fire door assemblies are. The general consensus is that because the doors are not fire door assemblies, the annual inspection and documentation is not mandated, but the doors, frames, and hardware must be kept in proper working order. Corridor doors that are fire door assemblies, such as doors leading to stairwells or incidental use areas that require a rating, would be subject to the annual inspection.  Doors required to comply with NFPA 105 – Standard for Smoke Door Assemblies and Other Opening Protectives would also have to be inspected annually, but the model codes do not require health care corridor doors to meet this standard.  The Joint Commission issued a bulletin clarifying this in 2018.

The requirements of the model codes have helped to reduce the frequency of fatal fires in hospitals and nursing homes, improving life safety for patients and staff. Properly-maintained corridor doors can help to protect patients sheltered in their rooms during a fire. For more information on the requirements for patient room doors in a health care facility, refer to the codes and standards that have been adopted by the facility’s jurisdiction. The AHJ is responsible for enforcing these requirements, and has the final say.

*Note: For doors protecting pass-through openings, NFPA 101 allows a maximum clearance of 1/8-inch at the bottom of the door.  These are typically small openings used for passing medication or equipment into the patient room.  Because the bottom of the pass-through door is normally above the neutral pressure plane that would occur during a fire, the clearance at the bottom of these doors is more limited than the clearance for a standard door.

For more information on codes and applications that apply to health care facilities, visit iDigHardware.com/healthcare.

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