Complying with door locking requirements

Designing code-compliant locking arrangements that meet the security needs of a patient population is often a challenging endeavor because of conflicting code requirements and the divergent goals of life safety and security. Equally challenging can be assessing existing locking arrangements to determine compliance with applicable codes.

The locking requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), and International Building Code (IBC) are more closely aligned than ever, thanks in large part to the American Society for Healthcare Engineering’s efforts.

This article focuses on the locking-arrangement requirements of the 2012 edition of NFPA 101 and the 2018 edition of the IBC. The LSC locking-arrangement terminology is used where the LSC and IBC use different language.

Facility professionals should review the LSC and IBC code references provided below for each locking method prior to designing new and/or reviewing existing locking arrangements as the requirements detailed are a summary of the code requirements.

Essential understanding

Understanding the security goal of providing a locked door is essential to designing a compliant locking arrangement. This can be accomplished by meeting with the person in charge of security to discuss the desired level of safety.

A review of the potential locking arrangements and their associated code requirements must then be performed to determine which arrangement is permitted to be applied to the situation. All requirements of a locking arrangement must be met to be code-compliant. Documented authorization from a local authority having jurisdiction (AHJ) must be obtained if all provisions of a locking arrangement cannot be met, such as complete building sprinkler protection.

General statements for each locking arrangement below are provided where both the LSC and IBC requirements are aligned. Statements that refer to a code are specific to that code only.

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• Delayed-egress locking systems (LSC 7.2.1.6.1 and IBC 1010.1.9.8)

Doors equipped with delayed-egress locking are required to open within 15 to 30 seconds upon activation of door hardware, which makes the arrangement less than ideal for units with patients who have certain clinical or security needs. However, delayed egress is often the best allowable locking arrangement for areas in which the patient population does not qualify for locking based on clinical or security needs.

Delayed egress is permitted to be installed in buildings with low or ordinary contents. The building is required to be completely sprinkler protected for early control of a fire or protected throughout by a fire-detection system to provide early warning of a fire. The door must also unlock upon loss of power to the locking mechanism and upon fire alarm/sprinkler activation.

An audible sound is required at the door when the release device is operated, which reassures building occupants that the system is functioning and alerts personnel that someone is about to pass through the door and, therefore, allows for time to investigate who is trying to use the door. The door may only be relocked manually after being unlocked via the manual-release device.

The door must be provided with the signage: “PUSH UNTIL ALARM SOUNDS” and “DOOR CAN BE OPENED IN 15 SECONDS.”

The IBC does not require the signage on the door where the patient population requires restraint or containment. The LSC no longer limits the number of doors in an egress path equipped with delayed egress. The IBC only allows a single door equipped with delayed egress in a required egress path to exit the building; however, there is an exception for Group I-2 and I-3 occupancies to allow a maximum of two delayed egress doors provided that the combined time delay is a maximum of 30 seconds.

In addition, the IBC also requires the capability of deactivating the delayed-egress lock from the fire command center or other approved location to eliminate the delay in opening the door in an emergency.   

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Access-controlled egress door assemblies (LSC 7.2.1.6.2 and IBC 1010.1.9.9)

An access-control locking arrangement requires the egress side of the door to be provided a sensor to unlock the door upon detection of an approaching occupant. A manual-release device located within 5 feet of the door with a label “PUSH TO EXIT” must also be provided on the egress side of the door as a redundant feature in addition to the motion sensor. Operation of the manual-release device must interrupt power to the lock and the door must remain unlocked for a minimum of 30 seconds, which provides adequate time to egress through the door.

The door must unlock upon loss of power to the locking mechanism or the motion sensor. The door must also unlock upon fire alarm and sprinkler activation and remain unlocked until the system is manually reset. Sprinkler protection is not required; however, if provided, sprinkler activation must unlock the doors. The LSC does not require fire-alarm activation via a fire-alarm manual pull station to unlock the door, which provides for a more secure arrangement.

The use of this locking arrangement is limited to doors required for egress from one side only as the egress side of the door must be provided with features to open the door. The locking arrangement is also rendered ineffective each time a person is close enough to activate the motion sensor that unlocks the door. However, the field of view of the motion sensor can be adjusted to reduce unwanted unlocking. It may be desirable to provide a second manual-release device more than 5 feet from the door in areas where patients are transported regularly. This allows the door to be open by the time the patient reaches the door.

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Electrically controlled egress door assemblies (LSC 7.2.1.5.6 and IBC 1010.1.9.10)

An electrically controlled door is considered a normal door assembly and not a special locking arrangement. In fact, the building occupant on the egress side of the door may not even realize the door is locked.

This approach may only be utilized when the secured side of the door is not required for egress. The egress side of the door must be provided with hardware affixed to the door that has an obvious operation method with the capability of being operated by one hand.

Operation of the door hardware via a built-in switch must unlock the door by interrupting the power supply of the electric lock. The door must also unlock upon loss of power to the locking mechanism.

This arrangement has limited application as it may be employed when the secured side of the door is not required for egress. It has an advantage over an access-controlled egress door in that a motion sensor is not required to unlock the door, making the arrangement more secure. 

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Locking for patients’ clinical needs or security needs (LSC 18/19.2.2.2.5.1 and IBC 1010.1.9.7)

Health care facilities contain certain units that permit locking based on the clinical needs of a patient or where patients pose a security threat. Examples that justify locking based on clinical needs are areas that treat psychiatric, Alzheimer’s and dementia patients. Examples that justify locking based on a security threat are forensic and detention units.

Doors are permitted to be secured for the clinical/security needs of a patient provided that staff can readily unlock doors at all times for the prompt release of patients by: (1) remote control of locks from within the locked smoke compartment; (2) keys carried by staff at all times; and (3) other such reliable means available to staff at all times.

Other such reliable means to unlock a door are often accomplished via a coded keypad or a badge reader. It is important to discuss the unlocking approach with an AHJ to ensure that a keypad or badge reader is considered a reliable means to unlock the door.

It is also important to coordinate staff access to keys or programming badge readers to unlock the doors where Options 2 or 3 are utilized. Some AHJs may require all staff, including interns and visiting staff, to be capable of unlocking the doors while other AHJs may only require staff responsible for relocation of patients.

An example of the importance of discussing a locking arrangement approach with the AHJ is that the Veterans Administration requires the locked door to be in the direct line of sight of the remote operator for Option 1 and requires a redundant manual key override where card readers are installed per Option 3. New installations permit only a single locking mechanism on a door while existing arrangements permit more than one locking device where permitted by the AHJ.

The IBC requires the building to be completely sprinkler-protected or provided with a smoke-/heat-detection system. The IBC also restricts the passage through a single door with this type of locking arrangement prior to entering an exit and also requires the capability of deactivating the lock from the fire command center or other approved location.

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Locking for patients’ special needs requiring specialized protection measures for their safety (LSC 18/19.2.2.2.5.2 and IBC 1010.1.9.7)

The LSC has long allowed health care occupancies to lock doors based on the clinical needs of patients. Over time, the clinical-needs locking approach was being used to justify the locking of doors to protect pediatric patients or secure an emergency department (ED) while the original intent of the provision was to apply only to psychiatric-type units. Locking these areas reduced the level of life safety in the building due to the limited code requirements related to the clinical-needs locking arrangement.

The LSC 2009 edition addressed the issue by introducing locking arrangement requirements based on a patient’s special needs, which require specialized security measures, or where a patient poses a security threat. Similar requirements entered the IBC 2015 edition. The LSC annex provides pediatric and maternity areas and EDs as examples of areas where patients might have special needs that justify door locking.

Complete smoke detection is required throughout the locked space or a remote unlock button must be provided at a constantly attended location within the locked space. Most facilities choose to provide the remote unlock button due to the cost advantages and it has the added benefit of being one of the three allowable methods to unlock the door, which are the same as those detailed for clinical needs. The door must unlock upon loss of power to the locking mechanism. The door must also unlock upon sprinkler activation or area smoke detection provided throughout the locked space if provided in lieu of the remote unlock button.

Sprinkler protection must be provided throughout the building, although the LSC annex states that the AHJ may consider allowing special-needs locking where the secured smoke compartment and smoke compartments required for egress from the locked space are provided with sprinkler protection.

The IBC requires the building to be completely sprinkler-protected or provided with a smoke-/heat-detection system. The IBC also restricts the passage through a single door with this locking arrangement prior to entering an exit and also requires the capability of deactivating the lock from the fire command center or other approved location.

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Elevator lobby exit access door assemblies locking (LSC 7.2.1.6.3)

Elevator lobby locking is permitted by the LSC, but the IBC contains no such provision. This locking arrangement is desirable on units where limiting unauthorized access from the elevator lobby to the unit or floor is desired. There are 14 requirements related to fire alarm, sprinkler, lock release and emergency operations.

There are so many features required since the building occupant can leave the area only by getting back in the elevator or having staff unlock the door. A two-way communication system must be provided between the elevator lobby and a constantly staffed location where staff are trained and authorized to provide emergency assistance.

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Communication is essential

Communication among stakeholders early in the project is essential for designing code-compliant locking arrangements.

After the project team agrees on the approach, it must be presented to the AHJ for comment and approval. Facility professionals should retain documented AHJ approval of the design, especially when deviations from a strict interpretation of the code were permitted. Most accreditation and licensure surveyors will defer to the local AHJ’s approval.

Finally, a robust and compliant locking-arrangement design is only useful when it is installed correctly, so health facility professionals should be sure to communicate his or her expectations to installing contractors.

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Lennon Peake, PE, SASHE, is director of survey and assessment services at Koffel Associates Inc., Columbia, Md. He can be reached at lpeake@koffel.com.