By Jeffrey Combs, Executive Board Chair, National Fire Protection Association, Health Care Section 

Spending over 35 years as a fire marshal for a major health care organization, I have witnessed many changes in the area of fire prevention and protection. While technology may change, the basic tenets of effective fire protection remain consistent: Put simply, safety layering works. The need to balance active and passive fire protection is paramount since the systems complement one another.

Passive fire protection is a key pillar of effective fire protection in modern health care organizations. The use of fire-rated floors and walls to form compartments that contain fire to the point of origin is essential because it allows occupants who may or may not be ambulatory to egress safely at the same time as fire suppression activities occur. These requirements are well defined in both the International Codes® (IBC and IFC), and of course, the National Fire Protection Association’s “Life Safety Code” standard.

Once code compliant doesn’t mean always code compliant

When it comes to passive fire protection, proper firestopping and smoke sealing of building service penetrations can make or break the performance of those fire-rated floors and walls.  Even when new buildings are turned over fully code compliant, changes to building service elements is inevitable. Understanding the ways in which barriers can be compromised is paramount. For instance, we know that low-voltage cabling for voice and data is subject to frequent moves, additions, and changes over even a relatively short period of time. Because of frequent changes to building service areas, many health care organizations struggle with barrier compliance in the area of penetrations. In fact, The Joint Commission has cited unsealed or improperly sealed penetrations as one of its Top 10 Life Safety deficiencies discovered during surveys.

Proactively manage barrier penetration as building elements change

What can you do to manage barrier compliance in an environment such as a health care organization where change is both inevitable and frequent? An effective strategy that has served me well throughout my career has been taking proactive control of barrier penetrations to ensure ongoing code compliance. In the health care system where I work, we do not treat firestopping as an afterthought. We have developed a detailed standard that sets clear expectations for our own workers as well as for our architects and contractors. Tested and listed UL-certified firestop systems are preselected up front and then penetrations are built according to those tested and listed systems.

Utilize purpose-made firestop pass-through devices

Over the past decade, the market has seen a trend towards using purpose-made firestop pass-through devices in lieu of traditional UL-certified system installation methods utilizing caulk or putty. These pass-through devices eliminate many problems, including overfilled sleeves. This class of products can significantly improve firestopping for low-voltage cabling. Look for a pass-through device that requires minimal or no maintenance and no action to activate the internal sealing function. 

One such device we use in our facility has an additional benefit: the ability to leave in place cable pulling strings for future expansions. Look for a device that you won’t have to open or close to ensure smoke and fire compliance. That way you can remotely pull cables without having to remove many ceiling tiles or access concealed spaces. This also provides a safer environment because there is less of a risk of spreading infectious dust. And, we realize additional savings because we can keep the number of closed patient rooms and corridor ceiling intrusion to an absolute minimum.

Ensure ongoing training of installers and inspectors

In an effort to more easily procure UL-certified systems, we standardized our procurement to a single firestopping manufacturer that offers outstanding technology and a wide range of UL-tested systems, along with support in the form of training, input into our construction plans, and hand holding on the job site. With regard to training, we worked closely with our manufacturing partner to customize a training program to fit our specific needs and reflect our expected practices, and to provide installer and inspector training and qualifications. This is how we ensure that we obtain consistency, avoid problems upfront, and minimize the cost of the doing the job.

Maintain a culture of compliance

Preselecting and standardizing on products and firestop systems is a good first step, but an essential step to ensuring long term barrier integrity is to create an environment where compliance is requisite. There is no other option. Contractors who work in our facilities must pass our training exam, and follow our procedures. They know that they are being watched, and they take the process of restoring fire ratings and re-sealing penetrations quite seriously. They know that the firestop installations will be reviewed and must match approved UL-certified systems. This culture actually diminishes the time allocated towards inspections because better quality is built in.

The lessons accumulated over 35 years combined with our impeccable record of affording our patients and staff safety by managing barrier compliance over the long term are proof the concept works. Considering the total cost of ownership associated with standardization on the right firestop products and systems is the right approach to saving money now and later.

Contact Jeff Combs at