How to implement NFPA 99-2018

Learning objectives

• Understand methods for performing a risk analysis in a health care facility.
• Explore the new sections in the 2018 edition of NFPA 99: Health Care Facilities Code.
• Look at revisions to existing sections in the 2018 edition of NFPA 99.

One of the challenges designers face when applying the requirements of NFPA 99: Health Care Facilities Code is defining risk categories to the spaces in and affected by, their project’s scope. Previous editions of NFPA 99 gave prescriptive requirements for each type of room. This method allowed designers to quickly assign requirements based on the room name. The use of the term “space” instead of “room” allowed for the risk assessment to happen at varying degrees of granular analysis. This is to say that whomever was determining the risk category for a space would also determine the physical boundaries of the space being assigned.

In a patient room, for example, separate risk categories could be assigned to the patient bed area, the staff area, the family area and the bathroom. When determining the total required air changes per hour for a patient room, for example, designers can be left wondering if the total ACH is the average of each category for the associated air volume or just the most stringent category applied to the entire room.

Alternatively, an entire wing or floor could be classified as a single category as opposed to differentiating between the patient room, the corridor, the nurses’ station, public waiting areas, staff only areas, etc. It has been a challenge for designers to apply the changes in 2012 and 2015 NFPA 99 due to the question of who was responsible to assign the category.

The 2018 edition of NFPA 99 attempts to clarify who is responsible for determining the risk category of each space by defining a health care facility’s governing body. NFPA 99-2018 section 1.3.4.1 identifies that either the governing body or an appointed designee shall be responsible for determining the category associated with each space.

Risk analysis

Starting with the 2012 edition of NFPA 99, a risk analysis shall be performed to determine the category of the area or space. The application of the risk assessment follows a series of steps:

• Step 1 is to determine how the room or space will be used.
• Step 2 is to determine the possible risks to patients, staff or visitors if any of the systems should fail.
• Step 3 is the processes of associating the possible risk with the appropriate category.
• Step 4 is to reference the requirements in NFPA for the given system(s) that apply to the determined risk category.

The category definitions apply to chapters on system risk, equipment risk, emergency management, security and fire protection. The exception to performing a risk analysis is to assign the area or space as a category 1 space, being as this is the most stringent category.

While the strategy for assigning the risk category appears simple at first pass, the analysis can seem subjective. For example, a category 2 space is one where a failure of the system being evaluated is likely to cause minor injury to patients, staff or visitors. In the case of lighting, this is typically applied to the egress path and stairwells. In some projects the egress path and stairwell may be considered a category 1 space, given how other codes classify egress pathways. This process becomes more subjective when the designer considers that plunging any occupied space into total darkness will always pose a threat to the occupants of that space.

Some of the questions that can come up during the design process can include:

• Who defines a “minor” versus a “major” injury?
• Can any minor injury become a major injury due to infection or associated medical conditions?
• Are some people more susceptible to injury than others and should the most susceptible person be considered?
• When designers are tasked with associating risk categories with possible outcomes, is there a transfer of liability to the designer or firm?

NFPA 99-2018 covers an important update in the definition of the HCFGB. Section 3.3.72 defines the HCFGB as a “person or persons who have the overall legal responsibility for the operations of a health care facility.” The assessment process and outcomes must be documented. The annex goes further, clarifying that the definition does not include the authority having jurisdiction when that party has legal jurisdiction of the facility, the construction or the design. This excludes governmental agencies, such as The Joint Commission or Centers for Medicare and Medicaid Services.

This important clarification assigns responsibility to the health care facility itself for determining both the parties assigned as the HCFGB and the application of each category. While this can be good news for designers, meetings to determine risk and category need to be performed early in the project to define the associated system requirements.

Medical gas and vacuum systems

Another change in the 2018 edition of NFPA 99 is the creation of chapter 15, which is dedicated to dental gas and vacuum systems. The commentary in NFPA 99 identifies that this change was to clarify that category 3 medical gas and vacuum systems, previously assumed to be solely for dental systems, may apply to other facilities based on the risk assessment performed.

In chapter 5 on medical gas and vacuum systems, new sections include oxygen concentrator supply units in section 5.1.3.5.11 and 5.1.3.9, waste anesthesia gasses in 5.1.3.8.4.3, alarms and controls in section 5.1.3.9.4 and a new section 5.3 on category 3 piped gas and vacuum systems. Several chapter 5 sections also received references to chapter 6 for essential electrical systems, further enforcing the requirement for these systems to be on emergency power (with the system level determined by the risk assessment category).

The latest edition also clarified the requirements for zone valve locations for category 1 spaces, which was section 5.1.4.6.8 in 2015 and is now 5.1.4.6.2 in 2018. This revision clarifies that the dedicated zone valve box be both immediately outside the room and readily accessible. Surgical departments commonly contain stretcher alcoves and this section of code identifies that accessibility cannot be hindered by storage or equipment.

Designers need to consider the floor plan early in design to account for valve boxes. It is important to note that the space required for a zone valve box needs to include piping, which enters and exits on the sides (see Figure 2).

Chapter 6 on electrical systems was rearranged for 2018 to eliminate duplicated information and improve the “flow” of the information. As a result of this effort, every section is designated as having been revised, which does slow the process of identifying changes when reviewing the code. The commentary identifies that the 2018 edition continued with the efforts in 2015 to eliminate requirements for level 3 essential electrical systems in 6.6.1, due to the idea that NFPA 70: National Electrical Code requirements in article 700 set a minimum standard that would be suitable for all buildings, including level 3.

Minimal changes to the requirements of electrical systems were included in the 2018 edition, beyond the reorganizing effort. NFPA 99 continues its separation from NFPA 110: Standard for Emergency and Standby Power Systems in that emergency power supply systems and emergency power systems are classified by NFPA 110, not NFPA 99. This helps the designer understand why the phrase “essential electrical system” is used in NFPA 99. Certainly, parallels can be drawn between a level 2 system in NFPA 110 and a category 2 equipment risk category in NFPA 99 because the wording in classification is very similar.

Chapter 7 on information technology and communication systems received a new sections 7.3.3.5 on wireless phone and paging integration and 7.3.3.7 on clinical information systems. These sections also identify the requirements for system listing and assign the requirements of the section 7.3.3.7 to section 7.3.3.5. These new sections note responsibilities of the HCFGB for system risk assessments on the topic of redundancy.

As information systems are used for integrating patient care systems, the same risk assessment process outlined above applies. When evaluating the requirements for IT systems, the risk associated with equipment failure will drive the discussion as to the requirements of systems supporting the IT systems.

Safety improvements

Chapter 11 on gas equipment includes a new item 11.3.1 that identifies the HCFDB as being responsible for determining cylinder storage requirements, specifically what constitutes full cylinders. Chapter 12 on emergency management includes section 12.2.2.3, requiring resources dedicated to development and implementation of the emergency management program. Wastewater and IT are added to the list of essential utilities and systems in section 12.5.3.3.6.5.

Security vulnerability assessments in chapter 13 are required to be revised based on national or local events, per 13.3.2. Chapter 14 is identified as having compiled requirements for hyperbaric facilities collected into one section. Similarly, Chapter 15 is dedicated to gas and vacuum systems for dental facilities or spaces. Both chapters 14 and15 were revised to improve organization of information and to simplify the process of looking for system information.

As editions of NFPA 99 continue to evolve, the theme of each revision appears to be focused on improving the safety and reliability of health care facility systems and equipment. The change from prescriptive requirements based on space usage to a classification system based on risk assessment has left many designers feeling like they may be taking on additional responsibility and liability. The 2018 edition clarifies the responsibility of the health care facility’s governing body as opposed to earlier editions that appear to assign responsibility outside of the health care facility.

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