Understanding the fire safety requirements in NFPA 99-2012

Learning the fire and life safety requirements of NFPA 99 as they relate to hospitals and health care facilities is critical.

By William E. Koffel, PE, FSFPE; Koffel Associates Inc., Columbia, Md. June 11, 2018

Learning objectives

  • Know the basic premise of NFPA 99: Health Care Facilities Code as it pertains to fire and life safety.
  • Understand the risk assessment categories of NFPA 99, and how to apply them.
  • Review how NFPA 99 should be applied in health care facilities including hospitals.

NFPA 99: Health Care Facilities Code is an unusual document within the family of NFPA codes and standards, in that it covers many items that are not fire safety-related. However, it’s important to understand the standard’s fire safety-related requirements that will be discussed here. The primary focus of this article will be the standard’s fire safety-related requirements. The 2012 edition of NFPA 99 represents the most significant change from previous editions, and it is the edition that seems to be more likely used by health care facilities since it was adopted by the Centers for Medicare & Medicaid Services (CMS). The most recent version is the 2018 edition.

The 2012 edition of NFPA 99 took a long time to develop since the last edition was published in 2005. After the production of the 2005 edition, the Correlating Committee on Health Care Facilities made the decision to rewrite the document using a risk-based approach versus an occupancy-based approach. The basis for this change was centered on reflecting how health care is delivered as opposed to the use and occupancy or "name" of the facility in which the care is delivered. For example, if a patient needs medical gas, whether they are in a long-term care facility or a hospital, safeguards need to be in place to protect the patient and caregivers. This change allows facilities to use NFPA 99 to determine the risk to their patients from the procedures offered in their buildings, and it provides requirements to protect against those risks. Instead of basing requirements for certain systems and equipment based on the name on the front of the building, the requirements are based on a risk assessment of what would happen to patients or caregivers if the system was lost or compromised.

The fundamental question to be addressed when performing the risk assessment is whether injuries or deaths to patients or staff will occur should the system or equipment fail. The four risk categories are summarized as:

  • Category 1: Failure of the system or equipment is likely to cause major injury or death to patients or caregivers.
  • Category 2: Failure of the system or equipment is likely to cause minor injury to patients or caregivers.
  • Category 3: Failure of the system or equipment is not likely to cause injury; but rather patient discomfort.
  • Category 4: Failure of the system or equipment would have no impact on patient care.

There are some chapters that do not use the categories. Chapter 12 of NFPA 99 creates its own categories based on the role of the health care facility within the community. The requirements of Chapter 13 apply to all facilities as determined based on the Security Vulnerability Assessment (SVA) and actual security concerns that exist in the facility.

Other than assuming that everything is Category 1, NFPA 99 does not provide an alternative to performing the risk assessment (Section 4.2.2). While there are many codes that offer a risk assessment as an alternative option, NFPA 99 is unique in that the risk assessment is mandatory. The risk assessment should be performed based on an assumption that without the protective measures required by NFPA 99, the system or equipment will fail; and you do not consider the probability or frequency of such a failure. The protective measures required by NFPA 99 for the category of systems are intended to mitigate the risk by reducing the likelihood of failure; or providing a back-up should the primary system or equipment fail. Also, when doing the risk assessment, you do not need to consider any intervention by facility staff during the failure scenario. 

Applying NFPA 99

NFPA 99 applies to all health care facilities other than those in which home health care is provided. While most building and fire codes define a health care occupancy as one in which four or more occupants are not capable of self-preservation, NFPA 99 does not define a health care facility by its minimum occupant load, nor does it consider occupants’ capability of self-preservation. In other words, when health care is delivered, the equipment and systems must meet the requirements of NFPA 99 regardless of the number of patients for whom care is being provided.

The construction and equipment requirements contained in NFPA 99 apply only to new construction and new equipment. Existing systems and equipment are permitted to continue in use unless the code specifically states otherwise—or the authority having jurisdiction (AHJ) determines that the continued use constitutes a distinct hazard to life. The administrative requirements, which generally include policies and preventive maintenance requirements, apply to new and existing facilities, systems, and equipment.

Medical gas systems

The Technical Committee on Piping Systems classifies gas systems as Category 1, Category 2, and Category 3 based on the categories determined by the risk assessment. However, the overall requirements are very similar to the prior editions. Category 2 systems are Category 1 systems, but components can be simplex rather than duplex. A single vacuum pump, a single regulator, a single master-alarm panel, etc. is permitted in a Category 2 system. Originally, Category 3 systems were dental systems; however, starting with the 2015 edition of NFPA 99, the Technical Committee on Piping Systems has tried to provide a true Category 3 system.

Gas storage

The requirements for bulk storage are coordinated with NFPA 55: Compressed Gases and Cryogenic Fluids Code. Outdoor bulk storage mandates a minimum of two egress routes. There has been a specific attempt to clarify that nonflammable medical gas storage areas are not hazardous locations in accordance with NFPA 70: National Electrical Code. In conjunction with that, the former requirement that electrical fixtures be at least 5 ft above the floor has been deleted and replaced with a requirement that they be protected from damage. It was not the intent for the 5-ft rule to imply that there is an electrical hazard, rather it was to protect the electrical equipment from damage while the cylinders are moving. All the ventilation requirements have been moved to the new Chapter 9 on HVAC systems that first appeared in the 2012 edition. Chapter 9 now allows natural ventilation in lieu of mechanical ventilation, and more information has been provided for both systems. Except for medical air compressors, no motor-driven equipment is allowed in the same room with medical gas storage. It is not uncommon to find motor-driven equipment in the same room as medical gas storage in existing facilities, but this is one example where the requirements for new facilities do not apply to existing facilities.

Gas systems

It is important to note that the labeling requirements are retroactive. This includes labeling of piping, alarms, and valves. Inaccurate valve labeling is a very common problem in health care facilities and should be reviewed for accuracy. The problem tends to be more with zone valves and area alarms. Surveyors find that more than half of the hospitals have errors with the labeling of zone valves. Even in brand-new systems, problems have been found due to labels being based on architectural room numbers rather than the using the correct method of actual room numbers. The staff needs to have the ability to quickly determine what valve must be closed when there is a fire in the room.

Electrical systems

Although it appears that Chapter 6 (Electrical Systems) in NFPA 99 has not reacted to the risk assessment basis, it has by default. Just because a facility is called the XYZ hospital, it might not require a Type 1 essential electrical system (EES), based on the risk assessment. Once it is determined that a Category 1 EES is required, then Chapter 6 requires that a Type 1 EES must be installed. If Category 2 is required, then either Type 1 or Type 2 EES shall be installed. There are very few differences between Type 1 and Type 2 EES other than how the power is distributed.

All operating rooms are now automatically wet-procedure locations unless a risk assessment is conducted to show that a specific operating room is not a wet-procedure location. This is a reversal of the former requirements that wet-procedure locations were determined by the facility administration. This assessment is still required for other areas of the facility that might be wet-procedure locations. Note that this includes a change in terminology from wet locations to wet-procedure locations. This was to emphasize the difference between the NFPA 70’s "wet locations" and the use in NFPA 99 of "wet-procedure locations." A sink qualifies as a wet location in NFPA 70 but not in NFPA 99. The "procedure" must be wet under NFPA 99. 

IT and communications systems for health care facilities

Chapter 7 of NFPA 99 is a new chapter that focuses on minimizing vulnerability in a health care environment with a growing reliance on electronic communication and data storage. Numerous sections of the chapter remain reserved and will be developed in future editions. The chapter addresses system infrastructure for each category. Requirements are detailed for telecommunications entrance facilities (EF), where service from the telecommunication provider is received; telecommunications equipment rooms (TER), housing for central voice and data systems; and telecommunications rooms (TR), where equipment, cross-connections, and cable terminations are housed. Requirements pertaining to each type of room regarding its location within the building, power supply, security, environment, and suppression system are provided.

Power circuits for equipment in Category 1 and 2 EFs and TRs are required to be connected to the critical branch of the essential electrical system, while critical TER equipment must be connected to the life safety branch. Essential electrical system power is not required for Category 3 equipment. Each room must be equipped with at least one duplex receptacle, and the TER must have one per wall for service and maintenance. Temperature and humidity must be maintained at the manufacturer’s recommendations for all rooms. The EF and TER are required to maintain positive-pressure differential with surrounding areas, and HVAC systems must be connected to the equipment branch if Category 1, and the essential electrical system if Category 2. Redundant pathways and cabling are only required for Category 1 systems.

Chapter 7 also discusses requirements for nurse call systems including patient areas, emergency assistance, staff emergency assistance, and emergency resuscitation alarms. Category 1 nurse call systems are required to be audible and visible and listed for the purpose, while Category 2 systems are only required to be visible. Patient-area call stations are also required to be located at each patient bed. 

Emergency management in NFPA 99

Though emergency management was a topic included in the 2005 edition of NFPA 99, the 2012 edition focuses on the specific problems that health care facilities must consider when creating an emergency action plan. This differs greatly from the holistic and vague approach in the 2005 edition in regard to emergency preparedness. As years have gone by, the need for emergency management within hospitals has become more pressing. Events such as the World Trade Center, earthquakes, hurricanes, the Boston marathon bombing, mass shootings, and other tragic events have made emergency management (planning and coordination) a critical need in health care facilities. These disasters range from natural events to people-caused events, and medical facilities are the ones who touch all those affected, physically and emotionally. These incidents will continue to occur and impact the community. Chapter 12 helps medical facilities prepare for their roles and be available to continue to provide medical services.

Chapter 12 "provides those with the responsibility for emergency management in health care facilities with the criteria to asses, mitigate, prepare for, respond to, and recover from" any emergency. The focus of the entire chapter is to be as generally prepared as possible, not just for one type of disaster, but for "emergencies of any origin." It maintains the same general outline as previous editions: put someone in charge of coordinating an emergency management committee, create a diverse committee, and have the committee create and implement an emergency management program. This is where the 2012 edition separates itself from its predecessors.

First, the facility in cooperation and coordination with their city/state must choose the appropriate category, either they plan to be a part of an emergency response in the area and prepare for an influx of patients (Category 1) or they plan to manage their existing patients but no sudden influxes (Category 2). Once a facility has determined the appropriate category, it must complete a hazard vulnerability analysis (HVA). The HVA focuses on identifying and preparing for natural hazards, human-caused events, and technological events in relation to their impact on health care facilities, operations, the community, and staff. To do this, they focus on elimination and mitigation of hazards when possible, and creation of an emergency operations plan (EOP).

The EOP focuses first on maintaining means of communication between the parties inside the facility and communication with outside facilities and communities. It also considers resources, utilities, support activities, and security. Resources, especially emergency stocks of medical equipment, must be kept plentiful and up to date. In addition, evacuation needs are considered, which require the facility to consider what kind of staff, equipment, and vehicles it would need for an evacuation. Facilities must also review water, electric, HVAC, and fire protection system needs, and then determine how to ensure that these needs are met throughout any incident.

Beyond these physical resource needs, the EOP looks at strains on various aspects of the facility, such as mortuary services, transportation of patients and their paperwork, sanitation and cleanliness of patients, and documenting locations of patients and staff. Though the topic of safety was moved to Chapter 13, the EOP still requires safety and security to be considered, such as internal security, controlling people movement inside and outside of the facility, helping patients with special security or safety needs, and managing hazardous wastes. Beyond the HVA, facilities also must educate their staff, test their EOP, prepare to classify patients during a surge (risk to others, risk to self, or risk of death/permanent injury), and prepare a recovery process for after the influx of patients is taken care of.


The 2012 edition is the first version of NFPA 99 that dedicates an entire chapter to security management of health care facilities. Though security and safety are always important aspects within other chapters, Chapter 13 allows medical facilities to obtain a comprehensive list of issues that their facility is at risk for and then offers solutions for protection from each threat. This is a major improvement because, just as emergency preparedness has become more important, so has security. This chapter helps health care facilities protect against security issues that have become more prevalent as time has gone on, such as infant abduction, media control, emergency department vulnerability, medication storage, and patient-information storage. As technology use increases and improves in the world, security must improve to continue to protect each facility with regard to its direct needs.

The last aspect of the facility that is reviewed in the SVA is personnel, which includes staffing and drills. Staff is under specific scrutiny, including contracted work employees and security personnel. Background checks and drug testing are suggested as the best practices for ensuring "employees of high integrity" within the facility. Drills must be conducted and then evaluated for effectiveness at least once a year. In addition to drills, training for security personnel needs to include, at a minimum, customer service, emergency procedures, patrol methods, de-escalation training, use of physical restraints, and use of force.

Fire protection features in NFPA 99

Another new chapter with the 2012 edition of NFPA 99 is Chapter 15 on features of fire protection. For the most part, this is extracted from NFPA 101: Life Safety Code, but there are some notable items. Recognizing that this document will be used in conjunction with building and fire codes, there are numerous places where it states "in accordance with applicable building code, NFPA 101, or fire code acceptable to the AHJ." There is a definition for "defend in place," and then the document goes on to require fire alarm systems and sprinkler systems to be "coordinated" with the plan for defend in place. These requirements differ slightly from what is commonly found in building codes and NFPA 101.

NFPA 99, NFPA 101, and the 2013 edition of NFPA 13: Standard for the Installation of Sprinkler Systems allows patient sleeping-room clothes closets not exceeding 6 sq ft (0.55 sq m) in hospitals to not be equipped with sprinklers. This is in recognition of the very limited fuel load and small size. However, the sprinkler arrangement must be such that the sprinkler in the room does protect the total area of the closet should the closet door burn through.

There are also provisions for compact mobile storage as well as a large section on fire-loss prevention in operating rooms.

Through the changes in the 2012 edition, NFPA 99 provides health care facilities with features that the previous editions did not. It provides specific details to protect patients, caregivers, visitors, and buildings from inherent hazards faced in a health care facility. This is especially prevalent in the chapters on emergency management and security. NFPA 99 helps to create facility-specific assessments and requirements that ensure health care facilities are safe, secure, and able to provide required emergency services during a disaster.

William E. Koffel is president of Koffel Associates. He is chair of the NFPA Correlating Committee on Life Safety and a member of several NFPA technical committees. He is a member of the Consulting-Specifying Engineer editorial advisory board.