NHSScotland ‘Firecode’

Scottish Health Technical

Memorandum 82
Alarm and detection systems

Supplement A: Version 1
Automatic fire control systems and voice alarm
systems

This document forms part of

NHSScotland Firecode Edition No 3

NHSScotland, P&EFEx, April 2003

CD-ROM Contents
 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

Contents

About this publication page 3

1. Introduction and scope page 4

1.1 General application
1.4 Scope of SHTM 82: Supplement A
1.7 Use by competent persons
1.8 Consultation
1.10 Other NHSScotland Firecode guidance
1.11 Other legislation

2. Glossary of terms page 8

3. Automatic fire control systems page 10

3.1 Introduction

4. Voice alarm systems page 11

4.1 Principle

Appendix A – Record documents page 12

Disclaimer
The contents of this document are provided by way of guidance
only. Any party making any use thereof or placing any reliance
thereon shall do so only upon exercise of that party’s own
judgement as to the adequacy of the contents in the particular
circumstances of its use and application. No warranty is given as
to the accuracy of the contents and the Property and Environment
Forum Executive, which produced this document on behalf of
NHSScotland Property and Environment Forum, will have no
responsibility for any errors in or omissions therefrom.

The production of this document was jointly funded by

the Scottish Executive Health Department and
the NHSScotland Property and Environment Forum.

Guidance revised 1 April 2003.

All previous versions are superseded.

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

About this publication

This Scottish Health Technical Memorandum (SHTM): Supplement A provides

guidance on the provision of automatic fire control systems and voice alarm
systems in NHSScotland healthcare premises.

The development of SHTM 82: Supplement A recognises that in patient access

areas of healthcare premises, there are many occasions where in the event of a
fire:

i) patients cannot be moved or moving them presents a health risk;

ii) minimum staffing levels required to move patients are greater than
minimum staffing levels required for cost-effective healthcare provision;

iii) warning systems that provide information to occupants significantly reduce

response time and support adaptive behaviour.

The installation of an automatic fire control system provides an approach to

addressing i) and ii) above and the installation of a voice alarm system achieves
the benefits of iii) above.

SHTM 82: Supplement A was prepared for NHSScotland Property and

Environment Forum by Glasgow Caledonian University under the auspices of a
national and multi-agency working group and following wide scale consultation
with NHSScotland. Design guidance and regulatory requirements on the
provision of automatic sprinklers in healthcare buildings in Australia, Canada
and the USA has been analysed during the preparation of this document.

The term ‘Trust’ used herein means an NHSScotland Trust/Board, Island Health
Board and NHS Property Holding Bodies. In due course the term Health Board
may replace Trust e.g. NHS Borders.

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

1. Introduction and scope

General application

1.1 This SHTM 82: Supplement A provides recommendations and guidance

additional to the recommendations and guidance contained in SHTM 82: ‘Alarm
and detection systems’ and should be read in conjunction with SHTM 82.

1.2 While the incidence of fire in healthcare premises is low compared to that in
other buildings, the consequences of a fire in healthcare premises are
especially serious because of the difficulties and health risks associated with
the emergency evacuation of patients, many of whom will be highly dependent
on life support equipment and staff assistance.

1.3 The technical guidance and recommendations contained in this document

should be considered in the design of new healthcare premises and major
extensions/refurbishments to existing healthcare premises to which SHTM 81 is
applicable.

Scope of SHTM 82: Supplement A

1.4 The main purpose of this document is to provide guidance on the provision of
automatic fire control systems and voice alarm systems in healthcare premises.

• Section 3 provides recommendations on the provision of automatic fire

control systems in healthcare premises;

• Section 4 provides recommendations on voice alarm systems in

healthcare premises.

1.5 The range of premises providing patient care facilities to NHSScotland patients
is extensive, and the guidance in this document may not be appropriate, in all
circumstances, for all types of building or specific areas of buildings. However,
it is expected that healthcare services and Premises Providers, Designers,
Building Control and Fire Authorities, will exercise a degree of judgement based
on a full analysis and understanding of the proposed healthcare premises
design, taking into account the factors listed below, the requirement to ensure
high levels of fire safety provision and the requirements of, and implications for,
operational and fire safety management. This Supplement should be
interpreted, and the requirements applied, with reference to the guidance
provided in NHSScotland ‘Firecode’ Edition 3, and particularly SHTM 81: ‘Fire
precautions in new hospitals’ and SHTM 83:’Fire safety in healthcare premises
– General fire precautions’.

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

Relevant factors include:

• the dependency of the patient;

• fire hazards within the premises;
• management policies;
• availability of sufficient and adequately trained staff;
• statutory and mandatory requirements eg Technical Standards, Scottish
Executive Health Department Fire Policy.

1.6 When using this document it is important to recognise that it is not possible to
make comprehensive recommendations covering all eventualities and it should
always be borne in mind that the purpose of healthcare premises is to provide
medical treatment, and/or nursing care or residential accommodation. The
complex nature and wide range of healthcare premises will sometimes require a
more flexible approach to ensure that the correct balance is achieved between
fire safety and the requirements for treatment and nursing care. The basis for
design decisions should be fully documented, as described in SHTM 81, and
provide a full justification of professional judgement applied and the context of
the specific challenges presented by the healthcare premises. However, in all
circumstances, care must be taken to avoid compromising the safety of
patients, visitors, employees and contractors.

Use by competent persons

1.7 This document should be used by competent persons employed as:

• Property/Estates/Building/Engineering Officers, Facilities Managers and

Health/Fire Safety staff employed by a NHSScotland Trust;
• Architectural, Building and Engineering Consultants;
• Building Control officers;
• Fire Safety Consultants;
• Fire Officers of the local Fire Authority.
Persons will be considered competent where they have sufficient technical
knowledge, training and experience both to understand fully the requirements of
fire safety procedures and management involved, and to undertake properly the
measures referred to in this document.

Consultation

1.8 Due to the complex and changing nature of healthcare premises and the often
conflicting requirements between fire safety and nursing care, including staffing
levels, it is essential that early consultation takes place between the Design
Team, the Trust Fire Safety Advisor and all relevant enforcing authorities.

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

Depending on the nature of the scheme it may also be appropriate to involve

the client’s insurers in the consultation process or take cognisance of CNORIS.

1.9 The installation of an automatic fire control system cannot, in itself, ensure that
in all circumstances patient evacuation can be avoided, or limited to the room of
origin. It is a provision that complements other fire safety provisions, such as
sub-compartmentation. Neither can the design and installation of a fire alarm
system ensure that all occupants of the healthcare premises respond
adaptively. However, the guidance in this document should reduce, within the
bounds of what is reasonably practicable, the probability of exposing patients to
the trauma of evacuation or untenable conditions, if it is not practicable to move
them, in a fire emergency. Furthermore the requirements of this Supplement
ensure that visitors, staff, contractors, etc, are provided with information that will
improve the response to fire alarm evacuation.

Other NHSScotland Firecode guidance

1.10 This Supplement to SHTM 82 should be read in conjunction with the guidance
contained in the latest revisions of the following NHSScotland Firecode
documents:

SHTM 81, Version 3 Fire precautions in new hospitals

SHTM 82, Version 2
SHTM 83, Version 2
SHTM 84, Version 3
SHTM 85, Version 3
SHTM 86, Version 3
SHTM 87, Version 2
SFPN 3, Version 2
SFPN 4, Version 2
SFPN 5, Version 2
SFPN 6, Version 2
SFPN 7, Version 2
SFPN 10, Version 2
Alarm and detection systems
Fire safety in healthcare premises – General fire
precautions
Fire safety in residential care premises
Fire precautions in existing hospitals
Fire risk assessment in existing hospitals
Textiles and furniture
Escape bed lifts
Hospital main kitchens
Commercial enterprises on hospital premises
Arson prevention and control in NHS healthcare
premises
Fire precautions in patient hotels
Laboratories on hospital premises

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

Other legislation

1.11 Other relevant legislation includes:

• Fire Precautions (Workplace) (Amendment) Regulations 1999;

• The Construction (Design and Management) Regulations 1994 (amended
2000);
• The Management of Health and Safety at Work Regulations 1999;
• The Disability Discrimination Act (1995).

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

2. Glossary of terms

2.1 For the purposes of this document the definition of terms provided in Part A of
the Technical Standards to the Building Standards (Scotland) Regulations will
be used. The standards specified for hospitals in the Technical Standards
apply to all healthcare premises where there is patient access. The following
additional definitions also apply:

• circulation space: The communication routes both within the

department/management unit giving access to other parts of the hospital,
and to all necessary fire escape exits;
• fire hazard: A set of conditions in the operation of a product or system with
the potential for initiating a fire;
• fire precautions: Measures which can be taken to reduce the likelihood of
ignition occurring and/or to mitigate the consequences should ignition occur.
Precautions are considered under five headings, each of which is defined
below:
a) prevention: precautions to control potential ignition and fuel sources, to
ensure that fires do not start; prevention also includes general fire
precautions;
b) communications/detection and alarm: systems which inform the
occupants and fire brigade when a fire starts;
c) means of escape: enable the occupants of the building to escape to a
place of safety away from the effects of the fire;
d) containment: physical arrangements which contain the fire to the
smallest possible area, and control the threat to life safety and the
extent of property damage;
e) extinguishment: systems which ensure that the fire can be controlled
and/or extinguished quickly and with minimum disturbance to the
function of the healthcare premises and damage to its premises.

• fire resistance: Ability of an element of building construction, component or

structure to fulfil, for a stated period of time, the required load-bearing
capacity, fire integrity and/or thermal insulation and/or other expected duty in
a standard fire-resistance test;
• ignition sources: Heat sources or flames which will cause ignition;
• place of safety: A place where persons are in no danger from fire;
• progressive horizontal evacuation: Evacuation of patients away from a
fire into a fire-free compartment or sub-compartment on the same level;
• protected shaft: A shaft which enable persons, air or objects to pass from
one compartment to another, and which is enclosed with fire-resisting
construction;

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

• refuge: A place of temporary safety within a building; this should be an

adjoining compartment or sub-compartment capable of holding all those
threatened, without a significant change in floor level and from which there is
potential for further escape should that become necessary;
• Technical Standard(s): refers to the 6th Amendment of the Technical
Standards to the Building Standards (Scotland) Regulations 1990;
• SHTM/SFPN: refers to the versions of these documents contained in
NHSScotland ‘Firecode’ Edition 3.

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 SHTM 82: Supplement A: Automatic fire control systems and voice alarm systems

3. Automatic Fire Control System

Introduction

3.1 In healthcare premises, particularly in patient access areas, the immediate and
total evacuation of a compartment, or sub-compartment in the event of fire may
not be possible or desirable. Patients with restricted mobility, patients who use
wheelchairs, and bed-bound patients cannot negotiate escape routes,
particularly stairways, unaided. Patients under medication may require staff
assistance, and patients who are dependent on electrical/mechanical
equipment for their survival cannot always be disconnected and moved rapidly
without serious consequences.

3.2 In certain scenarios, due to the patient’s medical condition and/or dependancy
on electrical/mechanical equipment, it may not be practical or advisable to move
or disconnect the patient from such life support equipment. In this context the
evacuation of patients from their position of care is effectively a ‘last resort’ and
therefore available technologies should be used to minimise the probability of
this occurrence.

3.3 To both minimise the probability of occurrence of the requirement to evacuate

patients and to maximise the time available prior to this eventuality an
appropriate automatic fire control system should be installed throughout the
building.

Requirements

3.4 Taking into account the statement in paragraph 3.2, patient access areas and
adjacent areas below and/or above such areas should be provided with an
automatic sprinkler system complying with BS 5306: Part 2: 1990 amendment 1
and the latest edition of the Loss Prevention Council (LPC) Rules for Sprinkler
Installations. These steps should allow a very high degree of protection for
highly dependant patients, which may reduce the need for patient evacuation
and allow staff to remain in attendance for a longer period of time.

Sprinklers should not be installed:

• in any room where the application of water, or flame and water combining,
constitutes a serious life or fire hazard;
• in any room or space where sprinklers are considered undesirable because
of the nature of the contents;
• in generator and transformer rooms separated from the remainder of the
building by walls and floor/ceiling assemblies having a level of fire safety
performance of long duration
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4. Voice Alarm Systems

Principle

4.1 Voice alarm systems can provide significant benefits in terms of reduced
response time and improved information dissemination, factors that are critical
in a healthcare environment. The provision of such systems must be
considered in the design of new healthcare premises and major
extensions/refurbishments to existing healthcare premises and/or the fire alarm
systems provided in these premises.

4.2 In considering the areas of the healthcare premises to be provided with a voice
alarm system, the desirability or otherwise of providing patients with information
regarding the fire and factors such as background noise levels must be taken
into account.

Requirements

4.3 Where these are installed voice alarm systems must comply with the guidance
BS 5839: Part 8 ‘Code of practice for the design installation and servicing of
voice alarm systems’.

4.4 The wording of the message on the voice alarm system should be clear,
unambiguous and precise. A coded staff alert message may be desirable in
some circumstances.

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Appendix A – Record documents

A1 To adequately assess the automatic fire control system, at the design stage a
set of drawings should be prepared using symbols based on BS 1635, and in
accordance with the requirements of BS 5306: Part 2 and the latest edition of
the Loss Prevention Council (LPC) rules for sprinkler installations.

Notes: These should be included in the Health and Safety File

A2 During the construction of a project, variations to the automatic fire control

system may occur for instance as the result of spatial re-organisation or
redefinition. These variations should be agreed with the relevant enforcing
authorities and should not vary from the requirements of BS 5306: Part 2 and
the latest edition of the LPC rules for sprinkler installations. The variations
should be recorded on the fire plans so that on completion an ‘as built’ set of
drawings can be prepared.

A3 The ‘as built’ drawings should be held by the Trust so that any proposed future
alterations can be checked against the drawings to ensure that integrity of the
automatic fire control system is maintained in accordance with the
recommendations in this document.

A4 In addition to drawings, records of the testing and commissioning of all

automatic fire control systems should be retained.

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