ASHE: LS.02.01.10

FOCUS on LS.02.01.10


Hospitals are designed, constructed, and maintained to minimize danger from the effects of fire, including smoke, heat, and toxic gases. In hospitals and other health care facilities, many occupants lack the ability to get up on their own and leave during an emergency. Patients who are incapable of self-preservation need special consideration during a fire or other life safety situation. The impracticality of completely evacuating health care facilities has led to decades of advancements in building protection features that allow people to remain safely within the building during an emergency. This defend-in-place approach has a long history of success in preventing injuries and deaths in health care facilities, but it is dependent on key building features such as fire and smoke barriers.


A review of the 2014 Joint Commission survey data indicates that fire doors and barrier management are key areas of noncompliance with Standard LS.02.01.10. For this standard, the issues and risks associated with noncompliance are similar across these two areas, and those issues and risks are outlined on this webpage (see below).  For specific mitigation strategies and resources for each area of noncompliance, visit the following links: 



Fire and smoke barriers installed in hospitals and other health care facilities are key elements of the structure. They protect occupants and are used for the horizontal evacuation of those in compromised areas. These barriers and their features form effective compartmentation that allows for defend-in-place strategies. Fire and smoke barrier management is critical to maximizing patient safety and property protection; minimizing death and injury; and facili­tating entry and travel in structures for emergency responders.
The proper design, installation, operation, and maintenance of building features are vital to the defend-in-place concept.  Without these systems, catastrophic outcomes could result. Since many patients are incapable of self-preservation and cannot respond to an emergency fire alarm, systems providing proper compartmentation are vital to properly protecting occupants. By using compartmentalized construction and fire suppression systems, fire and other emergency events can be contained at the point of origin, limiting the exposure and risk to patients, staff, and other building occupants.


During fire events or other life threatening emergencies within most structures, evacuation from the building is the best option. But in health care facilities, some occupants are physically incapable of self-preservation, so a defend-in-place strategy is the most appropriate way to handle these events. This type of strategy is dependent on the three elements: active fire protection, passive fire protection, and fire prevention.  The failure of any of these areas increases the risk of harm to those incapable of self-preservation.  Building features such as fire and smoke barriers, along with opening protectives, are key components of passive fire protection by providing protection from smoke and other byproducts of fire.  The failure to properly maintain and test fire and smoke barrier features significantly increases the risk to those who cannot take action on their own.

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