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Excerpt: Guide to NFPA requirements on fire extinguishing systems


July 1, 2019

The following is a short excerpt from the HCPro book The Life Safety Code Workbook and Study Guide for Healthcare Facilities. 

As was noted in this month's article on top fire safety violations, over 85% of hospitals were cited by The Joint Commission for EC.02.01.35—“The hospital provides and maintains systems for extinguishing fires.”

With that in mind, we’ve included a section of the Workbook and Study Guide dealing with fire extinguishment systems.


Automatic sprinkler systems are capable of quickly controlling a fire after inception, thus limiting fire damage as well as significantly reducing the risk to occupants. They stand ready to fight a fire 24 hours per day, without any assistance, and can do their job regardless of smoke-filled conditions.

All new healthcare facilities require complete automatic fire-extinguishing systems (automatic sprinklers). In existing healthcare facilities, sprinklers might be required, depending on the type of construction (see Module 11).

The Code requires the supervision of all sprinkler systems within healthcare facilities (monitored by the fire alarm system). Section 7, Automatic Sprinklers and Other Extinguishing Equipment, of Chapter 9 contains general provisions applicable to automatic and manual extinguishment systems within all buildings.

In addition, healthcare facilities have other requirements that slightly modify the general requirements of Section 9.7. Because Section 9.7 applies to all buildings, review these general requirements first and then proceed to Chapter 19’s requirements. Other modules in this Workbook & Study Guide address the requirements and benefits of sprinkler systems.

Code Review

Read the following sections from the Life Safety Code and remember to check any annex material indicated by the (*) notation:

  • 9.7
  • 19.3.5

Critical Issues for Existing Construction

Sprinkler systems

  • Where required, sprinkler systems must comply with Section 9.7
  • NFPA 13, Standard for the Installation of Automatic Sprinkler Systems, defines the design and installation requirements of automatic sprinkler systems
  • New cubicle curtains must comply with special provisions of NFPA 13, Standard for the Installation of Sprinkler Systems (i.e., curtain must have 1/2-inch mesh, 18 in. from ceiling)
  • Alternate protection permitted where sprinklers prohibited by the authority having jurisdiction (AHJ)
  • Must activate fire alarm system


When required by another Code provision or as an alternative, a distinct supervisory signal (electrical) shall be provided at a constantly attended location to indicate system impairment, such as the following:

  • Valve closure
  • Fire pump power supplies
  • Air pressure

Note: The Code requires supervision for sprinkler systems in healthcare occupancies

When supervision is required, water flow alarms must be transmitted to fire department or similar receiving location

Note: As noted in Module 23, the Code requires automatic fire department notification for all healthcare occupancies

Additional requirements for Healthcare occupancies:

Sprinklers required in accordance with minimum construction requirements. (Note: Module 11 addresses construction requirements, including need of automatic sprinkler protection.)

If sprinkler protection is required based on construction type or by an exception:

  • Must comply with Section 9.7
  • Must initiate fire alarm system
  • Must be supervised

Important: If is referenced, then it requires quick-response or residential sprinklers in all smoke compartments with patient sleeping rooms.

Standard response sprinklers permitted:

  • In hazardous areas
  • Where required due to listing limitations

Alternate protection

When the hazard present dictates an alternate form of automatic extinguishing system, it may be installed in lieu of a sprinkler system. Such system shall be installed in accordance with the appropriate NFPA standard:

  • CO2 (NFPA 12, Standard on Carbon Dioxide Extinguishing Systems)
  • Dry chemical (NFPA 17, Standard for Dry Chemical Extinguishing Systems)
  • Wet chemical (NFPA 17A, Standard for Wet Chemical Extinguishing Systems)
  • Halon (NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems)
  • Halon alternatives (NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems)

Manual extinguishing equipment

Portable extinguishers

  • Where required, must comply with NFPA 10, Standard for Portable Fire Extinguishers
  • Healthcare occupancies require portable fire extinguishers

Standpipe and hose systems

  • Where required, must comply with NFPA 14, Standard for the Installation of Standpipeand Hose Systems.

Note: Standpipe systems are not automatically required in any healthcare facility. They are required in any building that is a new high-rise healthcare structure (see 18.4.2 and

Sprinkler systems for isolated hazard areas

Sprinklers may be supplied by a domestic source in accordance with

  • Isolated hazardous area protection (
  • Maximum six sprinklers
  • Minimum 0.15 gpm per sq. ft.
  • Domestic water supply
  • Indicating shutoff valve

Maintenance and testing

Water-based systems

Per NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems

  • Sprinklers—Chapter 5
  • Standpipes—Chapter 6
  • Private fire service mains—Chapter 7
  • Fire pumps—Chapter 8
  • Water storage tanks—Chapter 9
  • Valves and fire department connection—Chapter 12
  • Impairments—Chapter 14

When a sprinkler system is out of service for more than four hours in a 24-hour period, must notify AHJ and either:

  • Evacuate building, or
  • Establish approved fire watch

Portable extinguishers

  • Must comply with NFPA 10, Standard for Portable Fire Extinguishers

Alternate protection systems

  • Consult appropriate design and installation standard (e.g., NFPA 12, NFPA 17, etc.)

What’s Different for New Construction?

18.3.5 applies to extinguishment requirements within new healthcare construction.

  • The Code requires complete building sprinkler protection in all new construction
  • Exception that applies to quick-response sprinklers not being required in hazardous areas has been removed for new construction in these areas


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