ILSM: Interim Life Safety Measures During Hospital Construction

When construction takes a life safety feature out of service, the hospital puts interim measures in place. What triggers an ILSM assessment, the measures on the list, and the contractor’s part.

What ILSM is

Interim life safety measures are what a hospital does to keep people safe while a life safety feature is out of service or compromised: an exit blocked by the work, a fire alarm or sprinkler system shut down, a rated wall opened. The Joint Commission requires them under standard LS.01.02.01, and the hospital decides which measures apply through a written ILSM assessment.

What triggers an assessment

• Work that blocks or changes an exit or path of egress.
• A fire alarm or sprinkler system shut down for the work.
• Fire-rated walls, doors or smoke barriers opened or penetrated.
• Any life safety deficiency that cannot be corrected right away.

The fire watch thresholds

In an occupied building, when a fire alarm system is out of service for more than 4 hours in 24, or a sprinkler system for more than 10 hours in 24, the hospital evacuates or notifies the fire department and starts a fire watch, and documents the times.

The measures on the list

• Signs showing alternate exits.
• Daily inspection of exits in the affected area.
• Temporary fire alarm or detection.
• Extra firefighting equipment.
• Temporary partitions that are smoke-tight or noncombustible.
• More surveillance of the construction area.
• Storage, housekeeping and debris removal that keep the fire load down.
• Staff training on the temporary conditions, and extra fire drills.
• Inspection and testing of any temporary systems.

The contractor's part

• Ask the hospital in writing before any shutdown of the fire alarm, sprinklers or an exit, with the start and end time. Each hospital sets its own notice period, so plan for it.
• Build and keep the temporary partitions and exit routes the assessment calls for.
• Keep the work area clean: no combustible storage, debris out every day.
• Restore systems on time and tell the hospital when they are back in service.

How BuildControl tracks this

When a shutdown request in BuildControl takes the fire alarm or sprinklers out of service, it says an ILSM assessment and a fire watch are needed. The assessment is logged on the job with its measures, its dates and who signed, beside the ICRA permit for the same work.

This is general information, not legal or regulatory advice. HCAI's, the Joint Commission's and each hospital's requirements change and differ by facility. Confirm anything here against the current published guidance and your project's approved documents before relying on it.