ASHE: LS.02.01.35

FOCUS on LS.02.01.35

LS.02.01.35 – The hospital provides and maintains equipment for extinguishing fires

Resources for Facility Professionals

When it comes to emergency responses to such issues as fires, hospitals employ a defend-in-place methodology. This methodology requires that active fire and smoke features, such as automatic fire sprinkler systems within the facility, are designed, built, and maintained appropriately.  These types of features are specifically required by codes and standards, and it is essential that hospitals design and maintain these features to control and contain fire and smoke at the point of origin.


Automatic sprinkler systems are key elements of the defend-in-place strategy employed by hospitals.  The proper design, installation, and maintenance of these features is critical to maximizing patient safety; facilitating entry and travel for emergency responders; and minimizing death and injury in an emergency incident.  Without these key elements, catastrophic outcomes could result.  Since many patients are incapable of self-preservation and cannot independently respond to an emergency, the proper control and containment of fire and smoke are essential to protect these individuals and allow for staff to respond and move patients at risk.

An automatic sprinkler system is a network of water-filled pipes that are distributed throughout the facility to provide proper coverage in a fire, thus controlling and containing the fire at its point of origin.  Sprinkler heads are designed with frangible bulbs or thermal linkages that, when heated, break and initiate the discharge of water.  Sprinkler heads are also designed with a diffuser to be able to properly distribute the water in a pattern to provide for adequate coverage of a specific area. This proper coverage is also dependent on the appropriate pressurization within the automatic sprinkler system. It is vital to ensure that the entire sprinkler system—from the fire pump to the deflector on the sprinkler head—is properly designed, installed, and maintained.


In other types of buildings, evacuation from the structure is often the best response to fires and other emergencies. But in health care facilities, evacuation could pose a greater threat to life for many of the occupants; hence a defend-in-place strategy is the most appropriate way to respond to these types of events within a health care facility. This type of strategy is dependent on three key protection features: active fire protection, passive fire protection, and fire prevention. LS.02.01.35 focuses on active fire protection features. The failure of any of these features can significantly increase the exposure of patients, staff, and visitors during a fire. In a fire situation, the vast majority of deaths result from smoke inhalation. Being able to control and contain the fire and the smoke and toxic fumes to the room of origin will not only limit the amount of combustion during the incident but, by keeping the smoke contained, will significantly reduce the risk to patients and staff.


Building systems such as automatic sprinkler systems are key components of active fire protection, providing protection from smoke and other by products of fire.  The failure to properly inspect, maintain, and test these features significantly increases the risk to those who cannot take action on their own.  In the 2012 NFPA Report “Major Hospital Fires,” Marty Ahrens noted that during the time period of 1980-1984, automatic extinguishing systems were present in less than half the fires reported by hospitals. On average, five deaths occurred due to hospital fires in each of these years. The report also detailed that from 2006-2010, automatic extinguishing systems were present in four out of five hospital fires, while sprinklers were present in almost two-thirds of these fires. On average, there were less than one death per year from hospital fires during this time. The NFPA report also states that flame damage was confined to the object of origin in 90 percent of recent fires, while 97 percent of hospital fires have been limited to the room of origin.  While there are many correlating reasons for these significant reductions, such as the ban of smoking within hospitals, it can clearly be seen that the significant increase in automatic sprinklers has helped to reduce the loss of life due to fires in hospitals.


A review of the 2014 Joint Commission Survey data indicates the following key areas of noncompliance to Standard LS.02.01.35:

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