Swinging doors in health care facilities are subject to myriad codes and standards requirements.

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Swinging doors installed in health care facilities are subject to myriad building, fire, life safety and accessibility codes and standards requirements.

Doors intended to protect the means of egress within these structures keep people safe as they move through the buildings in emergencies. Under normal conditions, doors provide security, privacy and convenience for occupants. Exterior doors also reduce energy costs by preventing heated and cooled air in buildings from escaping outside. Special-purpose doors (e.g., sound-resistant, lead-lined and bullet-resistant) provide added features.

These seemingly commonplace building elements are so complex that entire books can be written about them, their testing and maintenance requirements, and the codes and standards that dictate their use. In fact, the American Society for Healthcare Engineering has done just that with the recent publication of Inspecting and Maintaining Swinging Doors: A How-To Guide to Egress and Fire Door Safety. This article condenses part
of the introduction of that handbook.

Component-based systems

Regardless of where they are located in a building, swinging doors have several things in common. Typical swinging doors comprise a door frame, a door leaf, hinges and a latch or lock. When doors need to be kept closed, they have a self-closing device to ensure that they close every time they open. In other words, the majority of swinging doors  are component-based systems. Other arrangements of swinging fire-door assemblies include paired doors, sidelight frames, transom frames and combination sidelight-transom frames.

Because these types of doors are component-based, the door frame and door leaf might be products of the same or different manufacturers. Hinges and other door hardware can be products of various manufacturers. All of these components are assembled at the door opening to create swinging-door assemblies.

Where codes require that swinging doors meet certain conditions (e.g., direction of swing, minimum clear opening widths and fire-protection ratings) and/or have specific functions (e.g., fire-exit hardware or panic hardware, self- and automatic-closing functions, and unlatching operations), the doors are designed and equipped with the appropriate door hardware components.

Another thing the majority of swinging doors have in common is the process in which they are installed. Door frames are installed first, followed by attaching the door leaves to the frames with hinges or pivots. Latching, controlling and protective hardware components are the last products to be installed. Of these steps, door-frame installation is the single most important step in the process. Improperly installed door frames create operational and noncompliance issues that can be difficult to correct without removing and reinstalling them.

On new construction projects, door frames for installation in masonry walls are delivered early in the project. Masons erect and set these door frames in place before the walls are laid up. A misstep during the frame installation at this stage might not be discovered until much later when the door leaves and hardware are installed. Door frames in steel and wood stud partitions are either set in place before drywall is installed or designed to fit over (e.g., slip-on) the drywall. These door frames might be installed by rough carpenters, drywall contractors or others.

Door leaves are installed at various stages of the project. Exterior and perimeter door leaves are installed early in the process to control access and close the building envelope. Interior door leaves are installed much later.

Persons of various skill sets and experience are tasked with installing door leaves and door hardware; no formal door installation training or certification is required. Consequently, the operation and function of swinging doors are subject to the competencies of the installers. Malfunctioning and noncompliant swinging doors cannot be expected to perform reliably as required by the codes or as tested by the manufacturer.

There are, of course, exceptions. For example, some types of swinging door assemblies (e.g., aluminum doors and frames) are installed by the door and frame supplier (using their trained and experienced personnel), which reduces many of the operational and functional problems caused by poor installation. Also, door installation contractors have skilled personnel who install many different types of door assemblies.

Also, some types of swinging-door assemblies are unit-based systems, meaning that the door frame, door leaf, glass and glazing and hinges/pivots (and sometimes more hardware) are produced and packaged together as units. These doors are installed by factory-trained personnel, greatly reducing problems arising from poor installation practices.

Safety inspections

Several key points must be kept in mind regarding safety inspections of swinging egress-, and fire-door assemblies. Facility professionals should refer to these points often as they develop and implement their door-maintenance programs:

  • Door assemblies should be inspected in accordance with the code requirements that were in effect at the time of installation.
  • Door assemblies in a building are installed in compliance with applicable codes at the time of construction, providing the necessary level of fire-protection rating or fire-resistance rating for the area of the building in which they serve.
  • Door-assembly components are not required to be upgraded to meet current code requirements, provided they are maintained in working condition and do not pose a hazard to occupants.
  • Repairs to existing door-assembly components (e.g., large sections of clear wire glass) might require those components to be upgraded to current code requirements (e.g., fire protection-rated, safety glazing products).
  • Authorities having jurisdiction (AHJs) can require door assemblies to be upgraded to the current codes when they perceive the existing doors may pose a hazard to occupants.
  • For the fire rating of any swinging-door assembly to be valid, each component must be installed in accordance with its individual published listings and installation instructions, and the assembly must function correctly.

Code requirements

The National Fire Protection Association’s NFPA 80, Standard for Fire Doors and Other Opening Protectives, is a standard that covers the installation, inspection, testing and maintenance of several types of fire-door assemblies.

Perhaps the single most important point to remember regarding performing safety inspections of door assemblies is that most of NFPA 80’s requirements for swinging doors are general. By design, it 80 relies on the manufacturers’ published listings and installation instructions for many door-assembly components. When the listings or installation instructions for specific door-assembly components are not available or do not include the necessary detail, NFPA 80’s requirements prevail.

The first three bullet points in the previous section address the fact that codes do not require elements such as swinging-door assemblies to be perpetually updated as changes are made in the codes. To do so would place an undue burden on owners that would not be feasible to sustain for the life of the building.  The doors were designed to meet the code requirements that were in effect at the time of construction.

Accordingly, the fire-protection ratings of the doors can be relied on to provide the appropriate level of protection for the building areas in which they are installed. Fortunately, basic code requirements for swinging egress and fire doors have been relatively static over the past few decades.

The next two points address conditions that might warrant the need to upgrade certain swinging-door assemblies, when AHJs determine the presence of clear and present hazards to the occupants.

The final point might be the most important of all. The fire rating of the entire swinging-door assembly is only considered to be valid when all of its individual components are installed and the assembly functions as required by the codes. When non-fire-rated components are installed on the assembly or the door does not operate correctly for any reason, the fire rating of the assembly is considered invalid and therefore noncompliant.

Some door-assembly inspectors and AHJs might not be aware of the subtleties of code requirements for existing doors. At times, they might apply today’s code requirements to yesterday’s doors, which is not necessary in most cases. The upshot is that owners might unknowingly spend resources upgrading their doors when it is not required by the codes.

Interpreting and applying code requirements takes time, practice and a fair amount of patience, especially pertaining to swinging doors. Many times, subtle distinctions in the codes help to determine the correct way to resolve a situation.

Learning how to look up code requirements is a necessary skill for health facility professionals. Often the first reference they look up will refer to another section of the code or even another standard or referenced publication. In fact, the majority of answers depend greatly on the specific applications involved (e.g., occupancy use, fire-rated construction and presence of other systems such as sprinklers). Frequently, several references must be searched for a correct answer.

Codes are subject to the capabilities and limitations of the door-assembly components, adding yet another layer of complexity to the process. Another way of looking at this is that the broad-scope answer to a question might be “yes,” but the narrow-scope answer might be “no,” with “no” being the correct answer.

Ensuring movement

Ultimately, the purpose of a door-maintenance program is to ensure that people can move through buildings safely, especially in emergency situations. Security, convenience and controlling HVAC costs are important aspects of door-maintenance programs, but are secondary to protecting occupants. Often, complying with local codes is the impetus that requires doors to be properly maintained.


Keith E. Pardoe, FDAI, DAHC, CDC, CDT, is president of Pardoe Consulting LLC, Culpeper, Va. His email is kpardoe@pardoeconsultingllc.com.