Know the intent, changes of NFPA 99-2012
Health care delivery and administration has changed over the years and continues to evolve, not just for reimbursement reasons, but also for safer and improved patient care and more efficient staff use. Health care designers have adapted to the continual evolvement of health care delivery and to the increased focus on the patient. As that trend continues, each code review cycle focuses on current trends and needs to enhance its requirements. This is one reason that NFPA 99: Health Care Facilities Code was completely overhauled and rewritten from the 2005 edition to the 2012 edition and was changed from a ”standard” to a “code.” This change also reflects how it has been used, referenced, and adopted by authorities having jurisdiction (AHJ).
The overall rewrite of the document changed it from an occupancy-based document to a risk-based document. A major part of favorable procedure outcomes is to minimize the overall patient risk, and to do so, the risk first must be assessed, no matter where the patient is treated.
NFPA 99: Standard for Health Care Facilities was first published in 1984 as a combination of 12 separate health care related documents that were updated individually at nonregular intervals. A committee was formed in late 1979 and produced the first edition in 1982, which combined the 12 documents, and updated it in 1984. The 1987 edition made further changes to make a cohesive document and put NFPA 99 into a three-year review cycle like many codes and standards exist today. The 1990 edition further refined and correlated wording with other NFPA documents such as NFPA 101: Life Safety Code, and further organized the chapters and wording. The 1993 edition and 1996 edition incorporated industry changes and combined requirements into the same chapters. For 1999, a chapter on occupancy types other than hospitals was added, and enhanced essential electrical system testing requirements and Level 1 medical gas system requirements were revised. A focus on emergency preparedness was taking shape.
The 2002 edition included format and technical revisions to match and maintain consistency with other NFPA documents and increased the focus on disaster preparedness and recovery while maintaining services. Definitions were correlated to match other NFPA documents. Changes to the 2005 edition were mainly for clarity and better organizational structure, which brings us to the 2012 edition. The 7-year drought brought about significant changes to the document. The focus changed from an occupancy-based document to a risk-based document to reflect how health care is delivered and focused. It was changed from a standard to a code, which better reflects its use and adoption by AHJs. New specific focus chapters were added while occupancy chapters were deleted. Categories to establish risk were identified and included.
Specific updates and changes
Chapter 1, Administration, received minor changes. The most significant change is the addition of the phrase “other than home care” in paragraph 1.3.1. By inserting this phrase under application and deleting the previous occupancy chapters related to home care, NFPA 99 no longer applies to home care. Also, the word “standard” was replaced with ”code” to identify its new status.
Chapter 2, Referenced Publications, includes updates to NFPA standards and codes and other publications to reference current editions. The 2005 edition reference to NFPA 50 is removed as the bulk oxygen requirements have been moved to NFPA 55: Compressed Gases and Cryogenic Fluids Code, 2010 edition.
Chapter 3, Definitions, remains. Clarifications to some definitions related to the revised code language are included. Additionally definitions of terms such as battery powered light units, liquid oxygen container, defend in place, general anesthesia, levels of sedation/analgesia, and patient care rooms were revised to match the risk-based focus of the document. Definitions for Levels 1, 2, and 3 medical gas systems were removed. Paragraph 3.4, BICSI definitions related to telecommunications, was added.
Chapter 4, Fundamentals, is a new chapter. The previous chapter 4 information on electrical systems was moved to chapter 6. This chapter defines building systems categories and requires that building systems be designed to meet system categories 1 through 4. The categories are based on risk to the patient and caregiver and not on the location the procedure or service is performed. A defined risk assessment procedure must be used and documented to determine the category. The category definitions apply to chapters 5 through 11, and the facility systems must be designed to meet the category requirements as summarized below.
Category 1: Failure of facility systems or equipment is likely to cause major injury or death of the patient or caregivers.
Category 2: Failure of facility systems or equipment is likely to cause minor injury to patients or caregivers.
Category 3: Failure of facility systems or equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort.
Category 4: Failure of facility systems or equipment would have no impact on patient care.
Chapter 5, Gas and Vacuum Systems, was changed to match the Category 1, 2, and 3 definitions in Chapter 4. The Category 1 requirements are similar to the previous level 1 requirements in the 2005 edition and apply to health care facilities where failure of the systems may cause major injury or death to a patient, such as life-supporting ventilators. In section 5.2, Category 2 system requirements are very similar to Category 1, piped gas and vacuum system; however, some exceptions apply such as medical air compressors and vacuum pumps are permitted to be simplex. Category 3 piped gas and vacuum systems have less stringent requirements than Category 1 or 2. Of significant note is that deep sedation and general anesthesia shall not be permitted to be administered when using a Category 3 medical gas system. The revised code now includes enhanced information regarding testing and maintenance requirements that the facility must be aware of as well.
Chapter 6, Electrical Systems, contains information previously included in Chapter 4 of the 2005 edition and applies to both new and existing health care facilities. Paragraph 184.108.40.206.1.3, access to overcurrent protective devices (OCPD), was added and clarifies that only authorized personnel shall have access to OCPD (circuit breakers) serving Category 1 and 2 rooms. In addition, these protective devices shall not be located in public access spaces, but where used in locations such as critical care areas, isolated power panels shall be permitted in those locations. Paragraph 220.127.116.11.8.4 was added to identify that operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise. These wet procedure locations now shall be protected by either isolated power or ground-fault circuit interrupters. Previously these devices were noted as being permitted.
Paragraph 18.104.22.168.10 clarifies locations to be served by essential electrical systems (EES). Paragraph 22.214.171.124.11 clarifies where battery-powered lighting units are to be used and how they are to be tested.
Paragraph 126.96.36.199.2 on selective coordination was added under the Type 1 EES distribution heading. This code paragraph requires that OCPD serving the essential electrical system shall selectively coordinate for the period of time that a fault’s duration extends beyond 0.1 sec.
Chapter 7, Information Technology and Communications Systems for Health Care Facilities, is a new chapter and applies to IT and communication systems in all health care facilities that provide services to human beings. The chapter provides requirements for Category 1, 2, and 3 systems. The previous Chapter 7 on materials has been deleted.
Some specific items to note are the requirements for the Category 1 entrance facility (EF) and telecommunication equipment room (TER), including power to circuits shall be provided by the critical power branch of the emergency electrical system and all HVAC systems serving these rooms shall be connected to the equipment branch of the EES.
For example, if the building HVAC air system and chilled water system provides cooling, then these components must be connected to the EES. However, to avoid potential significant infrastructure and cost impacts, smaller separate HVAC systems should be considered. Also, no mechanical equipment or fixtures (piping of any kind, ductwork, pneumatic tubing) not directly related to the support of the room shall be installed in, pass through, or enter these rooms. Additionally, the EF requires at least 12 ft of separation from any permanent source of electromagnetic interference such as medical imaging equipment, transformers, motors, variable frequency drives (VFDs), and other medical or maintenance equipment. A positive pressure relationship for these rooms in relation to adjacent spaces shall be maintained by the HVAC system. Many paragraph titles in section 7.5 are noted as reserved, which indicates that this chapter will be expanded and new requirements may be included in future editions.
Chapter 8, Plumbing Systems, had previously not been included in NFPA 99. This new chapter is applicable to new health care facilities and to existing facilities that are being modernized, altered, or renovated. Existing systems and equipment that pose no distinct hazard to life are permitted to remain in use. The risk assessment performed by the health care facilities governing body shall designate the building system categories for the plumbing system in accordance with Chapter 4. The category of risk for the plumbing system shall be independent of any other building system serving the same space. The general requirements section identifies that most systems shall comply with applicable plumbing codes, but also clarifies where and how gray wastewater and clear wastewater may be used, and specifies that nonmedical compressed air shall not be used for medical instruments or for human respiration.
Chapter 9, HVAC, is also new andapplies to all new health care facilities and existing facilities that are altered, renovated, or modernized. Existing equipment and systems that do not constitute a distinct hazard to life are permitted to remain in use. Like Chapter 8, the governing health care body shall designate the building system category for the HVAC equipment and systems in accordance with Chapter 4 and independently of any other system serving the same space.
The chapter has several requirements to comply with other codes and standards, including ASHRAE Standards 170 and 90.1, and NFPA 45, 55, and 110. This chapter also requires that HVAC systems serving spaces or providing health care functions be commissioned.
Ventilation of medical gas storage and transfilling is required by reference to NFPA 55 and also allows both natural and mechanical means. Waste anesthetic gas removal by active or passive means is addressed in paragraph 9.3.8 with all exhausted air discharged externally to the atmosphere. The requirement for non-recirculation of smoke and venting products of combustion from an anesthetizing location contained in the 2005 edition under environmental systems (Chapter 6) has been removed. There is a requirement, however, that notes plumes created from medical procedures (laser and electrosurgical use) be removed and discharged outdoors, returned or exhausted through HEPA filtration, or returned to the space by means of chemical and thermal sterilization. Heating, cooling, and ventilating of the emergency power systems (EPS) room is addressed in paragraph 9.3.10 with specific airflow and temperature requirements in accordance with the EPS manufacturer and NFPA 110 requirements. These code requirements will now govern the HVAC installation in lieu of, or in some cases in addition to, other adopted guideline documents and standards.
Chapter 10, Electrical Equipment, is new and contains updated information from Chapters 8 and 10 of the 2005 edition. It applies to the performance, maintenance, and testing of electrical equipment in health care facilities, except home care as noted in Chapter 1. It was noted that several of the previous manufacturer requirements were removed as these same requirements were published by other agencies and organizations responsible for medical device approval such as the U.S. Food and Drug Administration and its branch the Center for Devices and Radiological Health.
Many specific wording changes and additions occurred in paragraph 10.2, Performance Criteria and Testing for Patient Care Related Electrical Appliances and Equipment, and paragraph 10.3, Testing Requirements. Paragraph 10.5, Administration, has been revised in several areas and now requires testing intervals be established by written policies and procedures before the equipment is first put into service and when modified, in lieu of the specific 6- and 12-month intervals noted in the 2005 edition. Also revised was the paragraph related to electrical equipment used in oxygen-enriched atmospheres.
Chapter 11, Gas Equipment, is the previous chapter 9 in the 2005 edition. Several minor changes were made to sections 11.3, Cylinder and Container Storage Requirements; 11.4, Performance Criteria and Testing; 11.5, Administration; and 11.6, Operation and Management of Cylinders. A new section was added, 11.7-Liquid Oxygen Equipment, which requires the oxygen seller and manufacturer to provide documentation and instructions for use, operation, storage, protection, handling, and related safeguards.
Chapter 12, Emergency Management, has been rewritten to be more in-line with the risk-based document and other organizations that require written emergency preparedness and disaster management plans. An application matrix is included with Category 1 and 2 requirements identified.
Chapter 13, Security Management, is a new chapter with its scope defined as those individuals responsible for security to develop a security management program and conduct a security vulnerability assessment (SVA). Security sensitive areas as identified by the SVA shall be protected as appropriate. Access and egress security measures must be developed. Additional sections on media control, crowd control, security equipment, security management, and operations are also included.
Chapter 14, Hyperbaric Facilities, previously Chapter 20 in the 2005 edition, applies to new facilities, with portions of the chapter also applying to existing installations. A new requirement to have a fire sprinkler system in rooms with Class A, B, and C chambers has been added. Previously, this was required for rooms with Class A chambers only. Lithium and lithium-ion batteries are prohibited from use in the chamber during operation, unless specifically tested and listed for that purpose (188.8.131.52.17.5). Additional requirements for chamber gas supply monitoring have been put into place (184.108.40.206).
Chapter 15, Features of Fire Protection, is also a new chapter. It applies to all new and existing health care facilities and requires compliance with NFPA 101 or the fire code acceptable to the AHJ. The chapter includes sections on utilities; fire detection, alarm, and communication systems; special hazards; automatic sprinklers; maintenance and testing; and similar topics.
Intent of the code
Annexes D and E of the 2005 code were removed. Chapters 11, 14, 17, 18, 19, and 21 were removed as these were primarily occupancy chapters with their own requirements. The 2012 edition with risk-based criteria removed the need for these occupancy chapters as the risk to the patient is now the driving factor.
While this article highlighted some of the changes, it is critical to read the actual wording and discuss the intent with the AHJ as it will enforce the adopted codes and standards. The 2015 edition of this code is in its revision cycle and currently is in its second revision; the final second draft was posted in January 2014 with the final issuance date planned for August 2014. Seven technical committees—electrical systems, fundamentals, mechanical systems, medical equipment, health care emergency management and security, medical gas and vacuum piping systems, and hyperbaric facilities—are addressing proposed changes and comments.
J. Patrick Banse has more than 35 years of experience in the consulting engineering field and is part of Smith Seckman Reid’s technical guidance team involved with codes and standards updates and QA/QC programs. He is a member of Consulting-Specifying Engineer’s editorial advisory board.