Fire Protection Requirements for Health Care Facilities - An Overview of NFPA 99

Fire Protection Requirements for Health Care Facilities - An Overview of NFPA 99

By William E. Koffel, P.E., FSFPE, James K. Lathrop, FSFPE, Sharon S. Gilyeat, P.E., Samantha M. White, Kristin R. Steranka, Koffel Associates, Inc.

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, this is not without precedent as one only needs to look at NFPA 70, National Electrical Code, to see a similar NFPA document. The primary focus of this article is the fire safety related requirements in NFPA 99-2012 Edition. While a more recent edition has been released, the 2012 Edition represents the more significant change from a previous edition and is the one that is more likely to be used by health care facilities, at least in the United States.

The 2012 Edition was a long time coming, as the last edition published by NFPA was the 2005 Edition. After the production of the 2005 Edition, the Correlating Committee on Health Care Facilities made the decision to basically rewrite the document using a risk-based approach versus an occupancy-based approach. The basis for this change was centered on reflecting what 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 there is medical gas needed for a patient, 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 provides requirements to protect against those risks. Instead of basing requirements for certain systems and equipment 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 can be summarized as follows:

  • 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

Some chapters do not use the categories. Chapter 12 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 by the Security Risk Assessment and actual security concerns that exist in the facility. By using this formatting, Chapters 12 and 13 keep true to the foundation of the 2012 Edition by focusing on risk assessment for the individual facility's needs.

Other than assuming that everything is Category 1, the Code does not provide an alternative to performing the risk assessment. While many codes 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-without considering the probability or frequency of such a failure. The protective measures required by NFPA 99 for the category of system 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, one is not to consider any intervention by facility staff during the failure scenario.


NFPA 99 applies to all health care facilities other than those in which home health care is provided. Most building and fire codes define a health care occupancy as one in which four or more occupants are not capable of self preservation. A health care facility, as defined by NFPA 99, does not have a minimum occupant load nor is capability of self preservation considered. In other words, when patient care is provided, 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 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.


The Technical Committee on Piping Systems renamed its Level 1, Level 2, and Level 3 gas systems to 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 are allowed to 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. Also, Category 3 systems are still really dental systems. For the 2015 Edition, the Technical Committee on Piping Systems has made an attempt to provide a true Category 3 system.

It should be noted that the paragraphs on retroactive requirements have been superseded by a TIA.1 This was because the paragraphs were written early in the revision cycle; as paragraph numbers were changed, the references in the retroactive provisions were not, resulting in incorrect references. (1. See Tentative Interim Amendment 12-4)

Gas storage. The requirements for bulk storage have been rewritten to coordinate with NFPA 55. Outdoor bulk storage now mandates a minimum of two egress routes. There has been a specific attempt to clarify that the storage of nonflammable medical gases are not hazardous locations in accordance with NFPA 70. In conjunction with that, the former requirement that electrical fixtures be at least 5 feet (1.5 meters) above the floor has been deleted, replaced with a requirement that they be protected from damage. It was not the intent for the 5 foot (1.5 meter) rule to imply that there was an electrical hazard; it was to protect the electrical equipment from damage during the movement of cylinders. All of the ventilation requirements have been moved to the new Chapter 9 on HVAC systems.

Chapter 9 now allows natural ventilation in lieu of mechanical ventilation; more information has been provided for either system. With the exception of 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. The author has observed that 50% of the hospitals surveyed have errors with the labeling of zone valves. Even in brand new systems, problems have been found because the labels are based on the architectural room numbers, rather than correctly using the actual room numbers. Staff need to be able to quickly determine what valve must be closed when there is a fire in the room.


Although it appears that the electrical systems chapter 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, Chapter 6 requires that a Type 1 EES must be installed. If Category 2 is required, either Type 1 or Type 2 EES shall be installed. Type 3 is basically what the Life Safety Code requires and is proposed to be eliminated in the 2015 Edition of NFPA 99. 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: This includes a change in terminology from wet locations to wet procedure locations. This was to emphasize the difference between the NFPA 70 "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.


Chapter 7 is a new chapter that focuses on minimizing vulnerability in a health care environment with a growing reliance on electronic communication and data storage. A number of 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 a telecommunication provider is received; Telecommunications Equipment Rooms (TER), housing central voice and data systems; and Telecommunications Rooms (TR), housing equipment, cross-connections, and cable terminations. 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 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 area, emergency assistance, staff emergency assistance, and emergency resuscitation alarm. 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 required to be located at each patient bed.


Though emergency management was a topic included in the 2005 edition, the 2012 edition focuses on specific problems that health care facilities must consider when creating an emergency action plan. This differs greatly from the holistic and vague approach that the 2005 edition took for 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 attacks; the earthquakes on the east coast of the USA in 2011; 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; 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 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 simply for one type of disaster but for "emergencies of any origin." It keeps the same general outline as previous editions: put someone in charge of coordinating the 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 in 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, community, and staff. In order 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 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-requiring the facility to consider what kind of staff, equipment, and vehicles it would need for an evacuation. Facilities also must review water, electric, HVAC, and fire protection system needs, and 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 safety was moved to Chapter 13, the EOP still requires consideration of safety and security such as internal security, controlling people movement inside and outside of the facility, helping patients with special security or safety needs, and managing hazardous waste. 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.


NFPA 99, 2012 Edition is the first edition 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 get a comprehensive list of issues that their facility is at risk for and 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 over time, 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 protect each facility for its direct needs.

The last aspects of the facility that are reviewed in the SVA are personnel, including staffing and drills. Staff are 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. Training and drills are the last aspect of the SVA. Drills have to be conducted and then evaluated for effectiveness at least once a year. In addition to drills, security personnel need to have training that, at a minimum, includes "customer service, emergency procedures, patrol methods, de-escalation training, use of physical restraints, and use of force.


Another new chapter with this edition of NFPA 99 is Chapter 15 on Features of Fire Protection. For the most part, this is extracted from NFPA 101, 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 says in accordance with " applicable building code, NFPA 101 Life Safety Code, or fire code acceptable to the AHJ." There is a definition for " defend-in-place" and the document goes on to require fire alarm systems and sprinkler systems to be "coordinated" with the plan for defend-in-place.

In NFPA 99, as well as NFPA 101 and the 2013 Edition of NFPA 13, sprinklers are not required in patient sleeping room clothes closets not exceeding 6 sq. ft. (0.55 sq. m.) in hospitals. This is in recognition of the very limited fuel load as well as limited size. However, the sprinkler arrangement must be such that the sprinkler in the room outside the closet protects the total area of the closet should the closet door burn through.

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

William E. Koffel, James K. Lathrop, Sharon S. Gilyeat, Samantha M. White and Kristin R. Steranka are with Koffel Associates, Inc.

The rewrite and re-organization of NFPA 99 resulted in the following chapters being deleted from the 2005 Edition:

  • All Occupancy chapters
  • Chapter 6 Environmental Systems
  • Chapter 7 Materials
  • Chapter 10 Manufacturers Requirements
  • Chapter 11 Laboratories

Also the following annexes were deleted:

  • Annex B Nature of Hazards
  • Annex D Safe Use of High-Frequency Electricity
  • Annex F Flammable Anesthetizing Locations

New chapters were added, including:

  • Chapter 4 Fundamentals
    Establishes "Categories" based on risk assessment discussed later in this article
  • Chapter 7 Information Technology and Communications Systems
  • Chapter 8 Plumbing
  • Chapter 9 HVAC
  • Chapter 13 Security Management
  • Chapter 15 Features of Fire Protection