With the publication of the ASSE/IAPMO/ANSI Series 6000-2021, Professional Qualifications Standard for Medical Gas Systems Personnel, we saw the creation of the new ASSE 6060 Medical Gas Systems Designer credential. In the three years since its publication, there has been growing interest from the design community and an abundance of people who have attended training, obtained the credential, and expanded their knowledge of medical gas piping systems. Starting with the 2024 edition of NFPA 99: Health Care Facilities, all Medical Gas Pipeline Systems (MGPS) must be designed by someone with an ASSE 6060 credential or equivalent competency acceptable to the facility’s governing body. With this interest and code requirement, it really has put a focus on how important the design process is for medical gas systems.
As an instructor of the ASSE 6060 courses, I have seen design-related challenges come up many times. Many designers are very experienced in doing design work, but have elected to take the course to expand their knowledge, understanding, and obtain the qualification.
The challenges do not go away after taking the course, but the course helps the designer to recognize them and provide acceptable solutions. Each class is taught using the most recent edition of NFPA 99. This means designers need to differentiate between locally adopted requirements and those found in the current published code edition discussed during the course.
With many locations still following the 2012 edition of NFPA 99 due to it being the latest revision adopted by the Centers for Medicare & Medicaid Services (CMS), many designs are solely based on the 2012 code. While the timeline for CMS to update to a newer standard is unknown, it is still important to consider the requirements found in more current editions of NFPA 99. If a designer solely looks at the 2012 requirements when designing a system, it is likely that there will be a problem or design conflict when moving to a newer standard. As some areas of the country are already moving from the 2012 edition to more recent editions, we are starting to see an increasing number of these conflicts and problems. Lack of consideration of newer requirements in the design process has resulted in a large financial cost to facilities required to add items compliant with codes that, while not adopted, were published and available at the time of their design.
The most common response to the differences is that the system was designed under the adopted code at that time and is therefore complete and compliant. However, with medical gas systems, the matter is a little more complicated. Within NFPA 99 there are numerous sections at the beginning of Chapter 5 that apply to both new and existing facilities. As soon as a local jurisdiction adopts a more current edition, those sections are applied to existing facilities as well as those being built or designed. Additionally, we quite often hear the term “grandfathered” in terms of code compliance and design. One of the other aspects of NFPA 99 is that there is no “grandfather clause,” for lack of better description.
One of the changes found in the recent editions of NFPA 99 directly impacts how these existing, noncompliant systems are evaluated. Non-conforming systems may remain in use, unless the authority having jurisdiction (AHJ) determines they pose a hazard to life. Previously the wording used was “if the AHJ had determined that the use did not create a hazard to life.” While it is just a small word change, the impact is great. Prior to the 2021 edition, any non-conforming use would have to be documented and then approved by the AHJ to remain in use. Now with the newer editions those systems can remain in use unless/until the AHJ determines they are unsafe. From a facility operational perspective this can have a significant impact.
The next significant change will impact anyone designing a facility for dental use. Prior to the 2018 edition, all piped medical gas requirements were found in Chapter 5. This forced dental facilities into the same grouping as medical facilities. Because the medical needs of a dental patient are very different than those in traditional health care buildings, the application of Chapter 5 was often less than optimal. In the 2018 edition of NFPA 99, a new Chapter 15 was created that directs all dental facilities to use Chapter 15, while traditional health care remains in Chapter 5. The new Chapter 15 continues to provide dental-specific requirements and should be applied in the design of dental facilities.
Since the 2012 code, we have also seen various new technologies, material requirements, and safety requirements added to NFPA 99. While many of these items are new requirements, it is still important to consider their inclusion in designs based on the 2012 code. In 2018 and newer codes, HEPA filters must be included on medical-surgical vacuum systems. While it may not be required in earlier editions, it is recommended these filters be included. If they need to be added later, a facility will often have to shut down the entire system. This can cause large-scale patient disruption and prove very costly.
We also saw the inclusion of on-site oxygen generation as an alternative to prepackaged oxygen cylinders or liquid oxygen supplies. These systems, when properly designed, can be an alternative to facilities that don’t have easy, cost-effective access to traditional oxygen supplies.
In the 2018 edition, we saw new requirements for a medical gas system inspection. While we still must complete all installer performed tests and verifier performed tests, the system inspection is a new requirement. The system inspection must be performed prior to concealing any of the piping. The inspection must be conducted by a certified individual who also is not the installation contractor. This inspector will witness the installers’ initial pressure test and ensure all systems are properly labeled and installed.
Since the 2018 edition, we have also seen some of the requirements regarding materials change. First off, the requirements for medical gas valves were revised. The wording of the valve requirements was updated to allow for new or different technologies of valves to be used. Most valves on the market today look the same as they did prior to the revision, but a manufacturer can now employ new valve types or technologies. The other very important change to valves is regarding the “purge ports” on the valves. While it was common for most in-line valves in the pipeline to have ports on both sides, it was not a requirement. It was also very uncommon for valves in zone valve boxes to have ports on both sides of the valve. In the 2021 code, it was added as a requirement that all valves, including zone valves, have a port on both the upstream and downstream sides of the valves.
In the 2015 edition we saw the introduction of auxiliary source connections for all medical gas systems. In 2018, some of those requirements were trimmed back to only liquid oxygen systems. However, following the very successful use of these connections during the COVID-19 pandemic for facilities that had them installed, auxiliary source connections are once again required for all piped medical gas systems in the 2024 edition.
The 2018 edition also added a new piping material for medical gas and vacuum systems. Corrugated medical tubing, or CMT, was added into NFPA 99 as an additional approved material for medical gas. The code requires any CMT product to be listed by a recognized listing organization, meet minimum safety and performance standards, and be installed and tested by the same personnel as any other piped medical gas system. The inclusion of CMT gives owners and designers another alternative to be included in the medical gas system.
Using CMT can greatly reduce the amount of hot work and lower the risk and impact on patients. Additionally, using CMT can allow for a facility to return to service more quickly following any interruption in their piped supply due to disruptions such as construction, maintenance, accidents or seismic events. CMT has proven beneficial enough for facilities that CMS issued a categorical waiver allowing any facility under CMS requirements (2012) to install CMT and be compliant with 2012 requirements. This waiver election does not have to be approved; it only is required to be documented by the facility.
The creation of ASSE 6060 and associated code requirements really has shown the importance of medical gas design. When designing a medical gas system, we must factor in the life-safety requirements of newer standards, even if we are designing to an earlier edition. While this can create a delicate balance with code and design compliance, project budgets, schedules, future planning, life safety, new technologies, and other associated requirements, keeping up with current credentials, codes, and other associated standards is vital not only to the design of the system, but also to patient safety. The integration of new and current technologies, codes, and safety requirements will only help our piped medical gas systems become safer, more robust, and better for all those whose life may depend on them.
