INTRODUCTION

Overview

This review series features the NFPA 99 Chapter 14 and is intended to provide insight as to how to interpret and utilize the guidance provided by Chapter 14 in daily hyperbaric operations. The series also provides insights on how to coordinate NFPA 99 standards with best practice standards to which clinical hyperbaric facilities are expected to conform upon facility (re)accreditation (e.g. Facility Accreditation by the Undersea and Hyperbaric Medical Society or UHMS).

The NFPA Chapter 14 applies to all hyperbaric facilities, regardless of occupancy (Class A, Class B or Class C) and is divided into three sections [1][2]:

14.1 Scope

14.2 Construction and Equipment

14.3 Administration and Maintenance

Although it may seem counter intuitive to begin this review series with section 14.3 (which is over halfway through the Chapter), section 14.3 was selected as the first topic because it details all administrative requirements that establish the foundation of the structure that needs to be in place for proper daily hyperbaric operations. Section 14.3 is of particular importance to facilities undergoing (re)accreditation by the UHMS, as it is often referenced in the UHMS Clinical Hyperbaric Facility Accreditation Manual.[3]

This topic is the first part of the review on section 14.3 'Administration and Maintenance' of the NFPA 99 Chapter 14. It covers codes related to the Purpose of section 14.3, Responsibility and Recognition of Hazards.

Background

In 2016 (May 4, 2016) the U.S. Centers for Medicare & Medicaid Services (CMS) published the document 'Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities' that required healthcare facilities to migrate from using the 2000 edition of NFPA 101®, Life Safety Code® (LSC) to the 2012 edition. CMS also mandated direct compliance with the 2012 edition of NFPA 99, Health Care Facilities Code.[4] This was the first time that CMS had a mandate regarding the NFPA 99.  Since the 2012 edition there have been several updated editions published, 2015, 2018 and most recently 2021. 

Relevance

In addition to CMS' mandate for hyperbaric facilities to to comply with the NFPA 99, regulatory bodies (e.g. the U.S. Food and Drug Administration), accrediting agencies (UHMS and The Joint Commission) and Authorities Having Jurisdiction (AHJ) utilize the NFPA 99 Chapter 14 to set their hyperbaric operational criteria. For instance:

• The U.S. Food and Drug Administration (FDA): the FDA regulates the oxygen used in hyperbaric oxygen therapy and the hyperbaric chambers (monoplace and multiplace chambers). FDA clearance of a medical device includes a determination that the device has the same intended use as, and is as safe and effective as, another legally U.S.-marketed device of that type.[5]
• In a post from "Get the Facts | FDA "(July 26th, 2021), the FDA advised that patients “check with your healthcare provider before using a hyperbaric oxygen therapy device to make sure you are pursuing the most appropriate care. If your healthcare provider recommends hyperbaric oxygen therapy, the FDA advises that you go to a hospital or facility that has been inspected and is properly accredited by the Undersea and Hyperbaric Medical Society.”[5] In the same post the FDA stated that “High concentrations of oxygen also pose the risk of fire, which is one reason why the FDA recommends treatment at an accredited facility.  Explosions and fires have occurred in hyperbaric oxygen therapy chambers that have not been reviewed by the FDA and are located at unaccredited facilities. 
• The UHMS: as seen above, the FDA statements regarding UHMS facility accreditation are significant. The UHMS facility accreditation program is recognized as a complementary arm of Joint Commission. The fundamental tenets of the accreditation program come from the NFPA 99 Chapter 14. The takeaway: understanding, developing and implementing policies/ operational procedures as stated in the NFPA 99 Chapter 14 is paramount to the provision of safe and effective hyperbaric oxygen therapy. The UHMS hyperbaric facility accreditation program (HFA) references numerous regulatory agencies and evaluates aspects of hyperbaric operation outside of the scope of the NFPA 99. For the purpose of this topic we will focus on the specific HFA probes that reference NFPA 99. The UHMS Clinical Hyperbaric Facility Accreditation Manual 4th edition will be referenced throughout this review.[3]  It is important to note that the Clinical Hyperbaric Facility Accreditation Manual 4th edition utilizes NFPA 99, 2015 edition. 
• The Joint Commission: The Joint Commission specifically addresses hyperbaric oxygen chambers under Environment of Care (EC) Standard EC.02.04.03 (which addresses medical equipment inspection, testing, and maintenance), Element of Performance (EP) 10: “All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99-2012: Chapter 14.” However, aspects of these complex spaces are further covered by other standards: fire safety training, in EC.02.03.01; utilities management, in EC.02.05.01; and medical gas management, in EC.02.05.09. Effective July 1, 2022, several revisions have been made to the “Environment of Care” (EC) chapter.[6] 
• For sample documentation required by the Hospital Accreditation Program Life Safety (LS), and selected Environment of Care (EC) standards refer to the 2021 The Joint Commission Life Safety & Environment of Care Document List and Review Tool.

SECTION: ADMINISTRATION AND MAINTENANCE 

NFPA 99 Section 14.3 provides guidance for standard operational procedure and structure, specifically on the requirements for administration and maintenance that shall be followed as an adjunct to physical precautions.[1][2]  The finer point(s) of this section are often misinterpreted or simply overlooked. It is important to note that the UHMS Clinical Hyperbaric Facility Accreditation Manual 4th edition utilizes NFPA 99, 2015 edition.[1] This topic will focus on the 2021 Edition.

Anatomy of Section 14.3 

Topic headings

Each section within NFPA 99 Chapter 14 is organized by topic headings. Headings of the section 14.3 in the 2021 Edition are listed below.[1] This topic will cover the first 3 headings of this section 14.3. The other headings will be introduced in subsequent parts of this Series.[2]

• Purpose
  
• Recognition of Hazards
• Responsibility
• Rules and Regulation
• Emergency Procedures
• Potential Ignition Sources
• Flammable Gases and Liquids
• Personnel
• Textiles
• Equipment
• Handling of Gases
• Inspection Testing and Maintenance
• Maintenance Logs
• Fire Protection Equipment for Class A Hyperbaric Chambers
• Electrical safeguards
• Furniture and grounding
• Electrostatic Safeguards
• Housekeeping

Annex A, B and C of NFPA 99

Supporting materials are located in the Annex, at the end of NFPA 99. The specific annex will be indicated by an A, B or C followed by the corresponding code (e.g. A.14.3.1.2).

• Annex A: Annex A provides helpful information, that is numbered to correspond with the applicable text paragraphs, and it is included solely to help the user of the document understand the intent of the requirements by providing further information, diagrams, and examples. The information provided in Annex A material is considered “official” commentary, as it is not only explanatory material for specific portions of the code, but it is voted on by the code’s technical committee, as is all material in the mandatory portions of the code. On the other hand, the commentary in this handbook consists of the opinions of the editors of, and contributors to, this handbook to help further explain provisions in the code.[1]
• Annex B: Annex B provides additional explanatory information on the main requirements of NFPA 99. This material includes details, in addition to those contained in Annex A, and provides helpful examples, historical contexts, and sample procedures and processes.[1]
• Annex C: Annex C contains sample ordinance to provide guidance in adopting NFPA codes and standards. Among others, these include NFPA 1, Fire Code; NFPA 30, Flammable and Combustible Liquids Code; and NFPA 55, Compressed Gases and Cryogenic Fluids Code. The sample ordinance in NFPA 99 is not part of the requirements of the code but is provided to assist a jurisdiction in adopting NFPA 99.[1]

Purpose 

• 14.3.1.1 – Is straightforward as it tells us that section 14.3 contains the administrative and maintenance requirements that should be followed.
• In addition, there is reference to the physical precautions specified in section 14.2. Section 14.2 contains the requirements for construction and equipment. Specifically, the minimum construction requirements, depending on classification, the design and installation of sprinkler protection, hyperbaric piping requirements, hyperbaric medical oxygen and medical air system requirements, fabrication of the hyperbaric chamber, illumination or lighting in the hyperbaric suite, chamber ventilation (class A and class B), temperature and humidity control, emergency depressurization, fire protection for class A,B and C, electrical systems, grounding and ground fault protection, communications and monitoring, combustible gas detection, other equipment and fixtures.

Recognition of Hazards

Recognition of hazards in the hyperbaric environment is not only identifying the hazards, but also the development of the policies, operational procedures.  This should include ongoing training and education of the hyperbaric team. The guidance and expectation is detailed the NFPA 99 code 14.3.1.2 and its Annex.

Responsibility

14.3.1.3 outlines the administrative, technical, and training requirements that must be developed and implemented to ensure the safe and appropriate utilization of hyperbaric oxygen therapy. This includes leadership of the facility, a governing board responsible for oversight of patient care and the safety of hyperbaric personnel. The requirement for the designation of a hyperbaric Safety Director is also included. Designation of the Safety Director should be documented in writing or should be part of an official process through your institution’s human resources department.

Hyperbaric Safety Director's background

As mentioned above, the UHMS Facility Accreditation Program is recognized as a Complimentary Arm of The Join Commission. UHMS facility accreditation probe HBOHR 2.2 looks for a Certified Hyperbaric Nurse or CHT on premises when chamber operations are going on. The individual designated as the Safety Director must attend a Hyperbaric Safety Director training course. It is acceptable for the hyperbaric safety director to be available by phone, and in our experience, this position is most often available 24/7 for calls regarding the hyperbaric facility.

It is the position of the NBDHMT that every recompression treatment facility and every clinical hyperbaric medicine service appoint a hyperbaric Safety Director. This position is consistent with a previous NBDHMT Position Statement regarding adherence to recognized codes and standards. It serves to emphasize what the NBDHMT considers to be a key safety aspect. The hyperbaric Safety Director should undergo formal and comprehensive training in the safety aspects of hyperbaric medicine and related technology. They should develop, maintain and manage a safety program based upon compliance with recognized standards. The resulting program should demonstrate effective elements of hazard mitigation, while employing recognized risk management concepts.

The Hyperbaric Safety Training Course is intended to be an Advanced Course that educates and aides in the development of critical thinking skills and how to develop the processes to evaluate safety issues. Consideration should be given to developing and establishing a Safety Team as a function of the Hyperbaric Safety Program.  

For further details see topics "Designation of Hyperbaric Safety Director" and "Hyperbaric Safety Director". 

I’m the new hyperbaric Safety Director… where is my office?

With regard to the term Safety Director: Safety Director is used for convenience. It is the intent of 14.3.1.3.2 to establish a set of safety responsibilities for the responsible person, regardless of the job title. The complexity of hyperbaric medicine is such that one person should be designated as the chamber operator. That person should be knowledgeable and have the training and experience to recognize hazards.

The National Board of Diving and Hyperbaric Medical Technology’s (NBDHMT) position statement regarding the term Safety Director is as follows: The term Hyperbaric Safety Director can be replaced with other titles of similar meaning and identical intent. Examples include Hyperbaric Safety Supervisor, Hyperbaric Safety Technologist, Lead Hyperbaric Safety Technologist, Hyperbaric Safety Manager, and Duty Hyperbaric Safety Technologist, and like terms. It is not the intent of the NBDHMT to assign a title. Rather, the intent of this Position Statement is to identify and emphasize the need for a trained and designated hyperbaric safety individual at each facility.

Other topic headings of section 14.3 of the NFPA 99 Chapter 14 are addressed in the second part of this review (coming soon).

CATEGORY A CONTINUING EDUCATION CREDIT

This topic has been reviewed and approved by the National Board of Diving and Hyperbaric Medical Technology (NBDHMT) for one (1) Category A Credit. 'Meeting the Category A requirement related directly to any combination of hyperbaric operations, related technical aspects and chamber safety.'

To claim the credit: 

• 1. Read the topic
• 2. Answer the examination and course critique questions. 
• Take the quiz via SurveyMonkey 
• 3. Receive the certificate by e-mail. A passing score of 70% is required (please allow up to 8 business days for processing)

For more information on Category A continuing education credits see blog post "Hyperbaric Certification and Continuing Education for Technicians & Nurses".