Q&A: Fire alarm systems and sprinkler systems (LS.02.01.34 and LS.02.01.35)

Accreditation Insider, May 1, 2012

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Q: What are the requirements for fire alarm systems and sprinkler systems?

A: Your hospital is required to have an approved operating fire alarm system. While manual pull stations are required for healthcare occupancies, smoke detectors are not required everywhere. There are basic requirements involving smoke detectors that are dependent on many variables in your hospital. In hospitals, smoke detectors are only required in elevator lobbies and mechanical rooms, waiting areas open to the corridor that are not directly supervised, above a fire alarm panel, and within five feet of a fire or smoke door that is held open by a magnet. In some situations, a hospital may have smoke detectors in additional locations based on local codes, state licensing requirements, as required for delayed egress locks, compensation for an equivalency, or just due to engineering preference.

Your hospital may or may not be required to have sprinklers. New construction requires sprinklers, but most existing construction types do not. Certain construction types require sprinklers regardless of if the facility is considered new or existing. However, there are many advantages to a fully sprinklered hospital, including:

  • Corridor wall construction no longer is required to be fire rated
  • Travel distance to exits increases by 50 feet
  • Construction for existing hazardous rooms is only required to be smoke-tight
  • Smoke dampers are not required in fully ducted HVAC systems in smoke compartment barriers

You must maintain at least 18 inches of clearance from the sprinkler head to items stored on the top shelf or any other tall object. The exception to this rule applies to shelves that are tight up against the wall and are not directly underneath a sprinkler head.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Beck at and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.

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