Firefighting in Hospitals

By Matthew Stiene

In each fire department’s response area, there are likely many different facilities. Fire departments need to conduct preincident planning and train regularly for responses to these facilities.

One of the most complicated types of facilities that a firefighter will ever respond to is a health care facility. This article will give firefighters an overview of health care facilities and some of the unique challenges they pose.

The National Fire Protection Association (NFPA) 99, Life Safety Code®, defines a health care facility as, “An occupancy used for purposes of medical or other treatment or care of four or more persons where such occupants are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the control of occupants.” “Incapable of self-preservation” means that the individual would not be able to get out of the building by himself in case of fire. Health care occupancies, according to NFPA 101are general hospitals, psychiatric hospitals, and specialty hospitals as well as nursing and convalescent homes, skilled nursing facilities, intermediate care facilities, and infirmaries in homes for the aged.

(1) A steam header. (photos by author.)


In addition to the problems posed by inpatient areas who cannot evacuate on their own, there are surgical procedures that cannot be stopped because of a fire. Other hospital challenges may include helipads, laboratories with significant quantities of flammable and potentially hazardous chemicals, equipment that requires specialized response including, MRI and CAT scan machines, liner accelerators, full-service commercial kitchens, large complex central energy plants, hazardous materials storage, and so on. While this may seem like a great challenge it is important to note that firefighters will likely encounter a well maintained facility, with a very knowledgeable staff where fire protection features are in good working order.

The use of NFPA 101 is an important distinction for health care facilities. While many local authorities having jurisdiction (AHJ) use the International Building Code and Fire Code, it should also be recognized that some use the NFPA 1, Fire Code, and NFPA 101 standards. When responding to a health care facility, the operators will likely be much more familiar with NFPA 101 because they need to comply with the Centers for Medicare and Medicaid (CMS) conditions of participation, which requires compliance with NFPA 101. In addition to CMS hospital operators, refer to several other regulatory agencies when discussing the Life Safety Code. These agencies include the Joint Commission (TJC), DNV GL (an organization that provides deemed status for CMS), or health care facilities accreditation program (HFAP). These organizations are authorized by CMS to accredit hospitals as conditions of participations and to receive payments from Medicare and Medicaid. Thus, health care facility operators use NFPA 101 as an operating manual for their life safety systems.

(2) An electric buss duct.


To understand the challenges that hospitals present, firefighters first need to understand the history of hospital fires. There are several NFPA studies and United States Fire Administration (USFA) articles on this topic which raise awareness of the issue. These articles include the following:

According to NFPA, between 1980 and 1984—the earliest years of detailed national data—fire departments across the country responded to an estimated average of 7,100 hospital fires annually, resulting in an average of five deaths per year. In the four-year period between 2006 and 2010, fire departments responded to an average of only 1,400 such fires that caused less than one death per year.1

The implementation of smoking bans at many health care facilities has led to a significant decrease in the number of fires started by smoking materials, from a high of 35 percent between 1980 and 1984 to seven percent between 2006 and 2010.(1) Additionally, automatic sprinkler systems were installed in new construction, while retrofitting existing health care facilities has increased significantly in recent years. Between 1980 and 1984, automatic sprinkler systems were present in less than half of the reported hospital fires, whereas between 2006 and 2010 automatic sprinkler systems was present in four out of five reported hospital fires, and sprinklers were present in almost two-thirds of the fires.(1) As the data indicates, fires in hospitals still occur; however, much work has occurred to make hospitals safer.

(3) Emergency power distribution.


Even though the numbers of fires has significantly decreased, it is still very important for firefighters to understand how they need to operate at a fire in a health care facility. The biggest difference between fires in commercial and residential structures and fires is that in a hospital, the occupants are not able to leave the building on their own during a fire. Inpatient areas are protected by moving patients horizontally from one smoke compartment to another during a fire. This is accomplished though a systematic process that will vary at each facility. Most facilities will ask all visitors to evacuate as they would in any other type of occupancy.

Staff from other areas of the facility and from various departments will respond to assist in the movement of inpatients. Staff will then begin the process of moving inpatients as quickly as possible; this may involve having patients move to wheelchairs, while others will be moved in their beds. Inpatients that can be moved easily and do not require additional equipment such as ventilators and other monitors will be moved, and those inpatients that have the greatest risk of movement will be moved as a last resort. All hospitals are required to conduct one fire drill per shift per quarter; it is beneficial for fire companies to participate in these drills to understand how the hospital reacts to a fire emergency.

(4) Normal and emergency power breakers.


A health care facility with inpatients follows the NFPA 101 standard as “defend-in-place” or a horizontal evacuation mode. Understanding the “defend-in-place” mode is the most important piece of life safety information for any that a firefighter needs to understand. All fireground tactics and objectives used to fight a hospital fire need to be implemented understanding that many inpatients will remain in place. For inpatients to survive, it important to know where the smoke compartments are constructed on the hospital floors. Work with the hospital’s director of facilities, tour the hospital, obtain a copy of the hospital’s life safety plans, identify the smoke compartments, and have a set of architectural floor drawings readily available at the hospital fire command center for an emergency response. Hospital preincident planning needs to be accomplished with the first-due companies or departments playing an integral role.

Additionally, it is very important to understand the fire protection features of the hospital. Although new hospitals built after 1991 are required to have full automatic sprinkler coverage, many existing hospitals may have either partial or complete sprinkler coverage. Because of their size, many health care facilities have a fire pump; where it is located; its gallons-per-minute rating; if present, the size of water tank and the fire reserve water capacity, and whether the fire pump activation is an automatic or manual operation. Firefighters need to know if the fire pump serves standpipes and/or the automatic sprinkler system.

(5) Steam boilers.


Firefighters also need to understand the fire alarm and detection systems in health care facilities. Many newer facilities have fully addressable fire alarm devices that will indicate the exact device that has activated. Although this is good information, the firefighters must know how to interpret the fire alarm device location and how to get there from the fire alarm annunciator panel. Older hospitals may still have a nonaddressable fire alarm system that will simply tell you zone where the alarm has activated.

Hospitals often are large complexes that may have multiple interconnected buildings. It is important to understand if the fire alarm systems in these buildings are tied together and how the alarms sound in connected buildings when a fire alarm device is activated in one building. Some hospital’s public safety or security staff may have done this prior to your arrival and will be able to assist firefighters in reaching the location of the alarm.

(6) Hazardous materials storage building.


It is important to build a relationship with the hospital public safety or security staff prior to arriving at the facility for an incident. In addition to the public safety or security staff, most hospitals have an administrator-on-call and a house supervisor. The administrator-on-call is a hospital administrator responsible for providing leadership at a facility. A house supervisor is responsible for facility operations outside of normal business hours; this individual is typically a nurse and is focused on the clinical operations but will serve as the incident commander (IC) in the event of an emergency until the administrator-on-call arrives. Like the fire service, the hospitals follow the incident command system, and the administrator-on-call/house supervisor will be the hospital liaison to the IC, who will likely not be on site after normal business hours (i.e., midnight to 8 a.m. on weekends) and will be responding to the facility once notified of the incident. Having a predetermined fire command center location and communication protocols are important building features that a hospital staff must understand and meet responding fire department as part of the pre-incident planning process. Based on research by Fire Department of New York Battalion Chief Greg Bierster, “This can be one of the most critical elements of your preincident planning.2 The fire department IC will need access to the hospital liaison and the staff leaders from the medical, safety, security, and engineering departments to mitigate a fire incident.

(7) Bulk medical gas storage.


When firefighters review the life safety plans with the hospital staff, it is also imperative to gain an understanding of the building(s) heating, ventilation, and air-conditioning (HVAC) systems, medical gas systems, fire protection systems, the electrical systems, and the emergency generator system serving the facility. In the event of a fire, most hospital’s air handling units (AHUs) are equipped with duct smoke detectors, which automatically shut down the fan in the unit where the fire occurs.

Air handlers also have manual emergency shutdown buttons typically located in the vicinity or the nurse’s station; NFPA 99, Health Care Facilities Code, requires manual shutdowns on all air handlers serving patient care areas.

The manual and automatic shutdown devices assist in preventing the movement of smoke throughout the air handling system.

Many older hospitals have 100-percent outdoor air systems; all of the air distributed through the air handler system is brought in from outside, and all of the air brought into the space is exhausted outdoors. The availability of a 100-percent outdoor unit can be very beneficial for overall operations. In addition per NFPA 99 hospitals are required to have smoke purge systems in operating rooms so surgery can continue in the event of a small fire. On activation, these systems will exhaust all air from the space and replace it with fresh air at the same rate the unit normally operates.

(8) Liquid oxygen storage.


Some hospitals also may have a fire alarm panel smoke control system. These systems are very similar to a smoke control system in other commercial facilities.   

Hospitals have medical gas systems that make use of oxygen, nitrous oxide, nitrogen, and carbon dioxide. These gases are typically stored in bulk tanks or in multiple larger cylinders combined at a manifold. The bulk tanks are typically located outside the facility, normally near a locking dock or receiving area. The tanks in a manifold system may be stored inside or outside, generally in the same location as the bulk tanks. Some of these gases are stored in a liquid form and they then expand to gas as they are used in the facility. These gases are then distributed throughout the facility and are segmented using zone valves. Zone valves allow isolation of the system; it is important to understand who is authorized to operate a zone valve. In most hospitals, the clinician in charge is the only individual authorized to operate the valve. In addition to these gases, hospitals will have medical air and medical vacuum. These two gases are produced on site using medical air compressors and medical vacuum pumps.

Electric power is critical to a hospital’s inpatient care and facility operations. Hospital’s electrical systems are typically very large and complex.

(9) Electric service entrance.


When responding to a hospital fire, disconnecting electricity is complicated for two reasons:

  1. The continual need for power even during a fire situation. It is not uncommon in a residential or commercial facility for firefighters to secure the power in the entire building or a portion of the building to eliminate the damage of electrical shock. When working in hospitals, firefighters need to know exactly what systems will be impacted when power is secured. The outcome of securing power without knowledge of the emergency power system that will be impacted may include removing power from inpatient medical equipment, operating rooms, intensive care unit areas, and so on. As discussed earlier, in many situations, operating room staff cannot simply stop surgery; they need to continue the procedure until the patient is stable and able to be relocated.
  2. All hospitals have emergency generation capability. Firefighters need to have a clear understanding of the emergency power supply system at hospitals. Firefighters need to know the generator room location, the areas supported by emergency power, and how that power is distributed. This will vary greatly based on the age of the facility. At a minimum, older health care facilities will have a life safety in equipment branch; new health care facilities will have a life safety, critical care, and equipment circuit branches.

The following circuit branch requirements are outlined in NFPA 99:

  1. The life safety branch is reserved for egress lighting and power needed for life safety systems such as fire alarm and suppression systems.
  2. The critical branch is reserved for power to inpatient rooms, medical air, and medical vacuums pumps.
  3. The last branch is the equipment branch reserved for items like HVAC equipment and elevators.

Another electrical utility issue to be aware of is multiple utility feeds into the hospital from the utility provider that serve particular areas of the facility with normal power. The areas supported by emergency power and how that power is distributed will vary greatly based on the age of the facility.

One of the best ways to gather preincident planning information is to work with the health care facilities management staff, which will have significant knowledge of the overall building system operations and fire protection features. It is critical that firefighters take advantage of the health care facility staff knowledge and document critical building information in the preincident plan for initial operations and beyond. Train all the firefighters on the availability of preincident plan information. It is important that the local fire companies and command staff as well as mutual-aid fire companies work with the health care facility personnel to coordinate the preincident plans into response actions so when the unthinkable happens, they are better prepared.

Once you have the critical building(s) information, it is important to document it in a manner that is readily available to any fire unit that may respond to the facility. Firefighters should also test the building information gathered when they have an opportunity. In many locations, hospitals have a significant number of activated alarms. When a company responds to one of these alarms, it should be used as an opportunity to test the preplan and the data that has been gathered from the hospital. Using this as a fire survey observations obtained during these alarms will provide a higher level of execution when they are needed for a more involved emergency.

Health care facilities across the country in large cities and small towns pose a very significant challenge and risk to firefighters. Hence, firefighters and command staff must learn about the hospital building features in their response districts and learn the building system features while they have the opportunity.

The key to being successful in fighting fires in hospitals is to understand how the buildings are designed to operate and how the fire safety features function under a fire or other type of emergency response. As with many things in firefighting, this requires training and preincident planning to deploy a decision-based knowledge for predetermined strategies and tactics. Having preincident building information will support various emergency situations, from initial operations by the first-due fire units to supporting further fireground operations.



1. Ahrens M. Major Hospital Fires. National Fire Protection Association, November 2012.

2. Bierster, G. Improving Fire and Life Safety in Hospitals. United State Fire Administration, 2010.


Matthew Stiene PE, CFM, is the senior director of plant engineering services at Novant Health.

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