Fire protection systems provide vital safety. Similar to brakes and airbags in a car that help protect passengers, fire suppression and alarm systems are integral to life safety in hospitals where defend-in-place is critical. Performing proper inspection, testing and maintenance (ITM) ensures the systems function as intended, and implementing the following best practices will help to increase reliability.

1. Establish asset-naming nomenclature and ITM testing procedures together. For example, a fixed-temperature/rate-of-rise heat detector requires different testing than a non-restorable fixed-temperature heat detector. 

2. Stress the importance of a living inventory of fire and life safety assets. For example, many new hospitals are built with a dual-monitor module for a sprinkler system’s waterflow and tamper switch. The monitor has two separate addresses. One pair of leads monitors the waterflow switch for an “alarm” condition and the other monitors the tamper switch for a “supervisory” condition. Frequently, ITM vendors will put two bar codes on the module (one for each test), which creates a duplication in the inventory and can lead to discrepancies. Set inventory standards internally, and train vendors to follow them.

3. Define what constitutes a failure to help prioritize repairs. Without this crucial conversation, an excess number of failures might appear on staff reports. For example, NFPA 72®, National Fire Alarm and Signaling Code®, prohibits smoke detectors from being within 36 inches of an HVAC diffuser; however, if the smoke detector fully operates and functions properly, this could be captured in the report as a “discrepancy” or “observation” instead of a failure. 

4. Have all necessary vendors on-site. For example, a fire alarm technician is only permitted to test to NFPA 72 and, without a sprinkler technician on-site, they might not be able to properly test the integrated components of the system, such as waterflow switches. These require water to flow to test the functionality of the switch.

This short list of considerations will help ensure your hospital’s fire protection ITM program is successful.

Josh Brackett, PE, SASHE, CHFM, system regulatory director, facilities, Banner Health.