1. NFPA 99 – 2012 Building a better medical gas maintenance program

2. Company Info  EMGS (Environmental & Medical Gas Services Inc.)  Moved into the medical gas market in 1989  Changed almost exclusively to medical gas inspections and sales in 1991  Started the education division in 1996  27 years inspecting, verifying and maintaining medical gas systems

3. Speaker Info  Cary Darden  14 years of medical gas inspection / verification and maintenance experience  Licensed medical gas installer (6010), inspector (6020), verifier (6030), maintenance tech (6040) and instructor (6050)  For the past 9 years the primary focus has been on helping facilities comply with NFPA 99

4. General Notes:  All references are taken from NFPA 99 – 2012 edition unless otherwise noted

5. Risk Categories – Chapter 4  Category 1 – failure of equipment is likely to cause major injury or death  Category 2 – failure of equipment is likely to cause minor injury  Category 3 – failure of equipment is not likely to cause injury but can cause pain or discomfort  Category 4 – failure of equipment would have no impact on patient care  For the purposes of this presentation we will focus on category 1 systems

6. CMS adoption of NFPA 99 – 2012 edition  Effective date: Tuesday, July 5 th 2016  As of this date existing facilities will need to comply with the requirements listed under NFPA 99 section 5.1.1.6  The new requirements mandate direct compliance with the 2012 edition of NFPA 99, Health Care Facilities Code for the first time  Previously NFPA 99 was only mentioned by extension through NFPA 101

7. What part of NFPA 99 did CMS adopt into law?  https://federalregister.gov/a/2016-10043  NFPA 99 – 2012 in its entirety with the exception of:  Chapter 7 – IT & Communications  Chapter 8 – Plumbing  Chapter 12 – Emergency Management  Chapter 13 – Security Management  CMS stated that they would not adopt chapters 7, 8 and 13 because they “had no authority to regulate these specific topics in health care facilities”  Chapter 12 was not adopted because CMS is addressing emergency preparedness in a separate rule

8. What part of NFPA 99 did CMS adopt into law? (Part 2)  TIAs (Tentative Interim Amendment)  TIA 12-2 – HVAC requirements (note 9.1.3)  TIA 12-3 – Chapter 6 Electrical  TIA 12-4 – Requirements for Existing Health Care Facilities  TIA 12-5 – Deletes 10.2.3.6(5) & corresponding Annex  TIA 12-6 – Elimination of sources of ignition (respiratory therapy / nasal cannulas)

9. Chapter 5 – Gas & Vacuum SystemsApplicability  5.1.1.4 – An existing system that is not in compliance shall be permitted to be continued in use as long as the AHJ has determined that such use does not constitute a distinct hazard to life.  5.1.1.5 – Sections applying to new health care facilities or facilities making changes that alter the piping  5.1.1.6 – Sections applying to existing health care facilities  TIA 12-4

10. NFPA 99 – 2012 TIA 12-4  Revises 5.1.1.6 to read – “the following subsections of this chapter shall apply to the operation, management, and maintenance of Category 1 medical gas and vacuum systems in existing facilities.” 1.5.1.2 2.5.1.3.1 3.5.1.3.2 4.5.1.3.3.1.7 5.5.1.3.3.1.8 6.5.1.3.3.4 7.5.1.3.6.2 8.5.1.3.8.5.2 9.5.1.14 10.5.1.15  Refer to document  “EMGS Explanation of NFPA 99 – 2012 TIA 12-4

11. Central Supply Systems  5.1.3.1 – Central Supply System Identification and Labeling  5.1.3.2 – Central Supply System Operations  5.1.3.3.1.7 – Cylinders shouldn’t be stored where they will get too hot (> 130°F)  5.1.3.3.1.8 – Nitrous Oxide and Carbon Dioxide Cylinders shouldn’t be stored where they can get too hot or cold (they need to be stored in areas that will keep them above -20°F* (+20°F in NFPA 99-2015) and below 125°F with respect given to manifold manufacturer’s recommendations )  5.1.3.3.4 – Central Supply System Storage

12. 5.1.3.6.2* – Uses of Medical Air  Medical Air Sources shall be connected to the medical air distribution system only and shall be used only for air in the application of human respiration and calibration of medical devices for respiratory application.  *Annex material A5.1.3.6.2 – The medical air system is not intended to be used for engineering, maintenance and equipment needs for general hospital support use.  Medical Air outlets should not be located in Endo / GI scope cleaning rooms or Central Sterile or Central Decontamination etc.

13. 5.1.3.8.5.2  Proper alternation schedules for motor driven central supply systems shall be established and maintained.  Medical Air Compressors  Medical Vacuum Pumps  WAGD Vacuum Pumps  Instrument Air Compressors where multiple compressors are used  This is an ongoing challenge

14. 5.1.14  Category 1 Operation and Management  Use this chapter and its associated annex material to build your medical gas maintenance program  Refer to Handout for 5.1.14 material

15. Steps to Compliance from 5.1.14 – Why Comply?  Why? – 5.1.14.2.1* Health care facilities with installed medical gas, vacuum, WAGD or medical support gas systems or combinations therof, shall develop and document periodic maintenance programs for these systems…

16. Steps to Compliance from 5.1.14 – What needs to Comply?  What? – 5.1.14.2.2.1 Inventories – generate an accurate inventory of your systems

17. Steps to Compliance from 5.1.14 – When?  When? – 5.1.14.2.2.2 Inspection Schedules & 5.1.14.2.2.4 Maintenance Schedules – establish your inspection schedules by your risk assessment (with a few exceptions, central supply systems, manufactured assemblies with hoses i.e. booms, etc.)  NOTE: Annex material A5.1.14.2.2.2 – facilities should consider annually inspecting equipment and procedures and correcting any deficiencies.

18. Steps to Compliance from 5.1.14 – When?  Every 36 months / every 3 years (+/- 45 days from the date of last event)  Every 12 months / annually (+/- 30 days from the date of last event)  Every 6 months (+/- 20 days from the date of last event)  Every 3 months / quarterly (+/- 10 days from the date of last event)  Every 30 days / monthly

19. Steps to Compliance from 5.1.14 – When?

20. Steps to Compliance from 5.1.14 – How?  How? – 5.1.14.2.2.3 Inspection Procedures – establish and document your procedures for ongoing inspections  NOTE: Annex materials for each individual piece of equipment to be inspected / tested / maintained

21. Steps to Compliance from 5.1.14 – Who?  Who may perform these tasks? – 5.1.14.2.2.5 Qualifications – establishes requirements for persons maintaining medical gas and vacuum systems.  3 options to comply with Qualifications: 1.Credentialing to the requirements of ASSE 6040 (outsource training) 2.Training and certification through the health care facility – train certain individuals to work on specific equipment (in house training to be an “Authorized Person”) 3.Outsource Maintenance to a third party – make sure that party is credentialed to do the work & get a copy of that credential to keep

22. 5.1.15  Category 1 Maintenance – simply mandates that a routine maintenance program be implemented and adhered to for all medical gas and vacuum systems.

23. NFPA 99 Maintenance Requirements & Risk Assessment  NFPA 99 states that all medical gas equipment should be maintained as per the manufacturer’s recommendations  Utilize risk assessment to establish your maintenance guidelines or follow the manufacturer’s recommendations  ***DOCUMENTATION = DATA***  How can you use the data gathered?

24. Case Study # 1  Medical air system failure  How much air does my facility use?  Total system run time * compressor capacity  How many bottles do I need to keep things online if my compressor system fails?  What can be done to ensure you and your respiratory staff are comfortable with your emergency backup medical air plan?

25. Case Study # 2  Oxygen system interruption  The oxygen system can be interrupted in a variety of ways  How much oxygen does my facility use?  Typically gotten from bulk oxygen supplier and is based on delivery schedules  How many bottles do I need to keep things online if my oxygen system is interrupted?  What can be done to ensure you and your respiratory staff are comfortable with your emergency backup oxygen plan?

26. Case Study # 3  Gas Manifold system interruption (N2O, Nitrogen, CO2, etc.)  The manifold systems are easily backed up by keeping a spare regulator on hand and having an auxiliary connection to your main line (i.e. alarm pressure switch)  How much of this gas does my facility use?  Keep usage logs for each gas manifold system  How many bottles do I need to keep things online if my gas manifold system is interrupted?  What can be done to ensure you and your respiratory staff are comfortable with your emergency backup oxygen plan?

27. Case Study # 4  Medical Vacuum system failure  The medical vacuum system is not so easily backed up  How much vacuum does my facility use?  Total system run time * vacuum pump capacity  Energy savings potential if tracked properly $$$  Redundancy via other medical vacuum systems in the facility  Portable vacuum producers located throughout the facility  Emergency Response Team  What can be done to ensure you and your respiratory staff are comfortable with your emergency backup medical vacuum plan?