Author(s): Richard Bielen. Published on January 1, 2009.

Going Under The Knife
Hospitals used to be the places where U.S. health care happened. Not anymore. An increasingly decentralized system, combined with a plethora of new, high-tech procedures, has radically reshaped health care in this country. Now NFPA 99 is being reinvented to more accurately reflect how we receive medical care—and to protect us against its risks.

NFPA Journal®, January/February 2009

By Richard P. Bielen, P.E.

NFPA 99, Health Care Facilities, is 25 years old. Despite a regular schedule of review and revision, the code has not kept pace with advances in medicine. Health care is a dynamic, rapidly changing field, with advances in equipment, procedures, and drugs occurring on an almost daily basis. Procedures that were performed just a year ago are suddenly outdated, and replaced by new ones. New kinds of facilities are offering a wider range of procedures to more patients than ever before. The rate of change, already dizzying, promises to only increase in years to come.

Recently, NFPA’s Technical Correlating Committee (TCC) on health care facilities examined the usefulness and adequacy of the standard. The committee measured the standard against a collection of fundamental questions: Is NFPA 99 still the one-stop document on health care? Does it reflect how health care is administered in health care facilities? After examining these questions, the answer was clear: NFPA 99 has not kept up with the multitude of fast-moving changes in the health care industry. It was time for a major revamping of the standard. A variety of health care technical committees has made suggestions to update NFPA 99; the proposed changes and comments related to the 2010 edition of the code will be up for adoption at the NFPA Conference & Expo® in June.

Currently, NFPA 99 is organized around occupancies such as hospitals, nursing homes, and limited care facilities. The standard addresses a facility’s infrastructure, including the electrical system, gas and vacuum systems, and environmental systems, as well as laboratory protection, health care emergency management, and protection of various health care occupancies. NFPA 99 has been updated every three years in an attempt to keep pace with the latest thinking and technologies, but the standard has not undergone a major overhaul since its adoption in 1983.

Over the last two-and-a-half decades, though, as the health care industry matured and became increasingly complex, the traditional structure of NFPA 99 became less useful and more confusing. For example, procedures that were once conducted exclusively in hospitals are now being conducted in doctors’ offices, ambulatory surgery centers, and other occupancies. The requirements for services such as gas and vacuum and electrical were different for these occupancies under NFPA 99, even though the risk to the patient for a given procedure was the same, no matter where the procedure was being conducted.

This lead the TCC to consider a new model for the updated NFPA 99. Instead of organizing the standard around where a patient receives treatment, the proposed retooling of NFPA 99 will be designed to minimize the risk to the patient, regardless of where treatment takes place. This new risk-based model is intended to protect patients while acknowledging the varying infrastructure needs among an array of health care facilities. The TCC has laid the foundation for the technical committees to rewrite the standard and identified areas that were not previously addressed, such as heating, plumbing, security, and information technology and communication systems, as subjects that must be addressed in the 2010 edition.

The name says it all. The title of NFPA 99 for the 2010 edition has been changed to Health Care Facilities Code to reflect the fact that it is no longer an installation document, but something much more comprehensive: a code that determines the performance criteria for health care facilities.

The birth of NFPA 99
The origins of NFPA 99 go back to 1979, when the Health Care Facilities Correlating Committee decided it was time to correlate and combine all 12 NFPA standards that addressed health care into a single document. These standards covered subjects ranging from laboratories, essential electrical systems, and hyperbaric and hypobaric facilities to emergency preparedness, inhalation anesthetics, and medical-surgical vacuum systems. One of the standards, NFPA 56, which addressed the use of inhalation anesthetics, dated back to 1941. As medicine developed and new procedures, drugs, and therapy options were discovered, new standards were developed to address fire and explosion hazards, as well as protection of patients, staff, and visitors.

The birth of NFPA 99 occurred in November 1983 in Orlando, Florida. The Health Care Facilities Correlating Committee presented its report in the form of a new document, NFPA 99, to the Association’s membership for approval. The membership agreed, and the Standards Council issued the fledgling document the following January as the 1984 edition. It’s interesting to note that some of the reasons the Health Care Facilities Correlating Committee used in 1979 to combine various standards were the same reasons the TCC used when it met in September 2005 to discuss modifying NFPA 99. In 1979, the Health Care Facilities Correlating Committee felt that combining all the standards into a single document would place them in the same cycle, eliminating confusion, and making cross-referencing each document easier. The standard would become a one-stop-shopping document for health care facilities.

Since its inception, NFPA 99 has been an essential document for a host of safety and regulatory concerns. NFPA 99 has been adopted by 36 states and numerous other jurisdictions and cities. It is referenced in NFPA 101®, Life Safety Code®, which in turn is referenced by the Center for Medicare and Medicaid Services (CMMS). To receive CMMS reimbursement for services, compliance with NFPA 99 is necessary. NFPA 99 is also used by The Joint Commission in its accreditation of health care facilities.

Standards are only as good as their last update, however, and the profound change that characterized the health care industry posed a particular challenge for NFPA 99. To bring the standard into the 21st century, the TCC had to rethink how the new standard would be used, and who would use it. The committee realized the prescriptive approach of determining the requirements for systems based on occupancies no longer works, and that a risk-based approach is necessary in order for users to develop their system requirements based upon what their facilities actually do.

These days, outpatient surgical centers and medical office operating rooms offer a lot more than LASIK eye surgery and mole removal, which makes the process of updating NFPA 99 even more timely. Extensive cosmetic, gynecological, urological, and dental procedures, as well as common cardiac and orthopedic surgeries—some that last for hours—are becoming increasingly popular in nonhospital settings. Rotator cuff repairs, ACL reconstruction, total hip replacement surgery, appendix removal, reconstructive plastic surgery, hysterectomies, cardiac catheterizations, angioplasty, stents, rotoblater for repair and removal of debris from the arteries—these are just a few of the hundreds of procedures being performed outside of the typical hospital setting. In coming years, many of these procedures will move from ambulatory surgical centers to office-based operating rooms, further removing them from the clinical setting of the hospital—and from the hospital’s redundant systems designed to minimize patient risk.

Considering that many of these procedures require the administration of general anesthesia, modern ventilation systems for infection control, specialized lighting, and power to operate medical and life support equipment, there is little doubt as to why these outpatient locations need the specialized environments, backup systems, testing programs, training, and utilities similar to those of a hospital.

The committee reasoned that for a facility to overdesign a system for the types of procedures it performs doesn’t make sense. Conversely, for a facility to underdesign a system doesn’t make sense either, because that makes it unsafe. The Technical Committee on Fundamentals was tasked with developing the framework for a risk-based approach that the other technical committees can follow when developing their chapters.

The Fundamentals Committee developed four different categories of risk. Category 1 includes facility systems whose failure would probably cause patients or caregivers major injury or death. Category 2 includes systems whose failure would most likely cause minor injury to patients or caregivers. Failure of Category 3 systems would cause patients discomfort, and failure of Category 4 systems would have no impact on patients.

A facility conducting procedures where patients are under general anesthesia, for example, would need to take patient risk into account when determining its systems requirements. Patients undergeneral anesthesia need airway management, which requires a reliable gas and electrical system; failure of one of these systems will likely cause major injury or death. The proposed new version of NFPA 99, therefore, would require the facility to maintain a Category 1 gas and vacuum system and electrical system containing the necessary redundancies and reliability for system or component failure. An example of a Category 3 system would be a heating or cooling system in the emergency room. If one of these systems fails, patients may be uncomfortable due to the temperature change, but would in all likelihood not suffer any injury.

New topics addressed
The updated code would also address a variety of new topics absent from the current standard. Security, for example, is a topic that has received much attention since the terrorist attacks on 9/11. Health care facilities are vulnerable to attack themselves, and they must deal with the aftermath of a terrorist attack, a mass casualty event, or a natural disaster such as a hurricane, tornado, flood, or earthquake. There are also internal security concerns that include medication diversion, infant abduction, and staff and patient safety. Because of these concerns, NFPA 99 has added a new chapter on security management.

Fire protection of health care facilities is an important aspect of the new code. The Life Safety Code addresses some areas of fire protection such as occupant loading, egress requirements, and when fire suppression and detection systems are required, but there are specialized areas in health care facilities that are unique and not addressed in any other NFPA document. The new NFPA 99 would add a new chapter that addresses the fire protection needs for health care facilities. It addresses compact shelf storage, audiometric booths and audiometric suites, walk-in refrigerators, and freezers. It also consolidates the requirements for protection of flammable liquids and gases, HVAC equipment, fire detection and alarm, elevator machine rooms, rubbish chutes, incinerators, laundry chutes, and sprinkler and extinguishing systems.

Information technology and communication systems are another new area NFPA 99 addresses. This chapter outlines the requirements for telecommunications entrance facilities and equipment rooms, as well as fire protection requirements for these spaces. Nurse call systems, including patient area call stations, emergency call, and staff emergency assistance call features, are also addressed in this chapter.

The new Technical Committee on Mechanical Systems developed new chapters on plumbing and heating systems. The plumbing chapter will not address gas and vacuum plumbing systems, but does address nonmedical compressed air systems, potable and non-potable water, water heating, water conditioning, and special-use water systems. The chapter on heating and ventilation systems addresses heating, cooling, ventilating, humidity control, and process systems. Natural and mechanical ventilation requirements are addressed when storing or transfilling medical gases. Ventilation systems for waste anesthetic gases disposal systems are also outlined in this chapter. In keeping with the standard’s new risk-based approach, the requirements for all of a facility’s systems vary with the level of risk to the patient.

These changes to NFPA 99 are long overdue. Incorporating a risk-based approach to selecting and designing systems for health care facilities will empower facility owners to choose the appropriate level of system based upon their needs and the procedures they conduct. Facilities will no longer be required to provide expensive, redundant systems based solely upon their occupancy if the results of their risk assessment do not warrant such a system.

The new standard, and the risk-based process it uses, will doubtless make some observers uncomfortable, while others will embrace it as a godsend. Ultimately, though, the changes proposed for an updated NFPA 99 will result in the right code at the right moment, one that is able to keep in step with the changes occurring in the health care industry. With a risk-based approach, users of the code will have the power to control their own choices, and can tailor their systems to meet their specific needs.

Richard P. Bielen is director of Fire Protection Systems Engineering for NFPA. He is staff liaison for NFPA 99.