Trust Procedures

The Safe and Secure Handling of Medical Gases Procedure

This Procedure applies Trust-wide

Document control page

Name of Procedure The Safe and Secure Handling of Medical Gases Procedure

Name of linked Policy Medical Devices Policy and Procedure

Accountable Director Chief Nurse and Deputy Chief Executive

Author with contact details Joanne Fowlis, Head of Resilience, Safety and Security (01925 664404) Carol Humphries – Pharmacist (0151 244 4599)

Status (draft/ ratified) Ratified

Ratifying Committee/ date Audit Committee August 2016

Review date December 2021

Brief description of changes following review

Harmonisation of Policy/Procedure across the Trust

Equality Impact Assessment The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This Procedure has been Equality Impact Assessed and does not discriminate.

Version control

Version number Development Timeline Date

V1.0 New Trust wide version 07.08.13

V1.1 Reviewed and updated in line with 3 year review date

11 July 2016

V1.2 Minor Formatting 12 July 2016

V1.3 Version following engagement and consultation

27 July 2016

V2.0 Final 28 July 2016

V2.1 Minor change – Trust name change April 2017

V3.0 Version following new SLAs and standardisation of oxygen cylinder

Jan 2020

Page 3 of 36

Contents Page

Page

1 Introduction 4

2 Scope 4

3 Cylinder Management 5

4 Obtaining Supplies of Medical Gases including ordering and receipt

5

5 Service Level Agreements 6

6 Storage of cylinders (including external storage and internal storage)

6

7 Entonox 7

8 Preparation for Cylinders to be returned to the Medical Gas Supplier

8

9 Signage 8

10 Transportation of Cylinders 9

11 Unloading of Cylinders 10

12 Handling of Cylinders and Storage 10

13 Using Medical Gas Cylinders 10

14 Cylinders Labelling / Markings 11

15 Returning Cylinders 11

16 Gas Leak Precautions 12

17 Fire and Heat Precautions 12

18 Combustible Materials 13

19 Ignition Sources 13

20 Fire Precaution Guidance 13

21 Other Fire & Heat Precautions 13

22 Chemical Hazards 14

23 E-learning 14

24 Incident Reporting 14

25 Records 14

26 Monitoring Compliance 15

27 References 16

28 Associated documents 16

29 References 17

Appendix 1 Tables (three) summarising responsibilities for Medical Gas stock checks, ordering & deliveries

18

Appendix 2 Bullnose cylinder – Guide to using with a regulator

21

Appendix 3 Medical Oxygen – Integral valve cylinders 27

Appendix 4 Entonox 31

Appendix 5 Medical Gas Pin Index cylinders 33

Page 4 of 36

1. Introduction

At North West Boroughs Healthcare NHS Foundation Trust [hereinafter referred to as “the Trust”] the aim is to provide and maintain safe and healthy working conditions, equipment and systems of work for all staff, and to provide such resources, information, training and supervision as needed for this purpose. The Trust will manage the risk of the Medical Gas by following the national guidance stipulated in HTM.02-01. Where Medical Gas is used within the Trust (in-patient units and community sites) it is administered from portable cylinders with integral heads and is the only Medical Gas provided.

The aim of this procedure is to give clear guidance on legislative and best practice guidance to safely manage Medical Gases.

It is essential that all Medical Gases and Medical Gas cylinders are stored and handled in such a manner that all risks associated with their supply, use and handling are minimised. This procedure sets out the framework and practice that the Trust must adopt.

This procedure applies to all staff who are involved in the clinical use, management, ordering, supply and maintenance of Medical Gases, including staff not directly employed by the Trust involved in any of the activities listed. Medical Gases are medicinal products under the provisions of the Medicines Act 1968. They are used in many critical health conditions and there is potential for serious harm if not administered or managed appropriately. This procedure is to be read in conjunction with Borough specific SOP’s and the Medical Devices Policy.

2. Scope

The procedure and associated standard operating procedures (SOPs) define the overall management, responsibilities, governance, and monitoring activities for the safe operation, distribution and management of Medical Gases and aims to ensure that systems are in place to manage and respond to local incidents and national alerts. A full list of properties/ buildings and status of occupation is available on request from NWBH Estates Department.

This procedure and associated SOPs cover the Medical Gases oxygen and nitrous oxide/oxygen50/50 (e.g. Entonox®). The standard operating procedures (SOPs) relating to this procedure are held on the trust medicines management pages.

This procedure does not cover the clinical use and administration of Medical Gases. Those matters are described in clinical protocols and standard operating procedures.

Page 5 of 36

Only healthcare professionals who have the knowledge and understanding of Medical Gases are permitted to administer Medical Gases to service users.

The Trust Resuscitation Policy details the emergency administration of oxygen for resuscitation purposes. Within Trust Walk-in-Centres both oxygen and Entonox portable cylinders are available. Oxygen and Entonox are administered under the direction of specific Patient Group Directions.

3. Cylinder Management

The Manual Handling Operations Regulations 1992 (as amended 2002) cover the handling and transportation of Medical Gas cylinders. A risk assessment must be performed by Trust units for all situations. Attendance at Manual Handling training is essential for all staff handling Medical Gas cylinders. The British Compressed Gas Association’s (BCGA) Guidance Note GN3 – safe cylinder handling and the application of the Manual Handling Operations Regulations to gas cylinders defines the principles of safe practice for the handling of compressed and liquefied gas cylinders. It explains how compliance with the Manual Handling Regulations may be achieved.

4. Obtaining Supplies of Medical Gases

See Appendix 1 for a summary of responsibilities for ordering, delivery, stock checks etc. relating to Medical Gases for each site & service in the Trust. Ordering and Receipt Medical Gases for Walk-in-Centres are obtained directly from the nominated supplier. See Walk-In-Centre SOP. Community sites that have the LifeLine Oxygen bags will obtain replacement cylinders direct from the nominated supplier – Community Services SOP. At Halton (the Brooker Centre), Warrington (Hollins Park) and Wigan (Atherleigh Park) site, Medical Gases are ordered from the approved Medical Gas supplier by the NWBH Estates Department. At Halton (the Brooker Centre), Warrington (Hollins Park) and Wigan (Atherleigh Park) site, Medical Gases are delivered by the nominated supplier and stored locally on site in a designated storage facility. Delivery of Medical Gas cylinders (including services users admitted to hospital and are oxygen dependent) is undertaken by the agreed portering services.

Page 6 of 36

On delivery of Medical Gases from the nominated supplier, the porter receiving the delivery must check that:

both the delivery note and the gas cylinders are clearly marked with the name of the supplier and the delivery date

the number and type of cylinders delivered matches the number and type of cylinders ordered.

Each Medical Gas cylinder must be inspected for damage and any noted to have defects returned to the supplier. For NWBH services at St Helens, Knowsley and Halton Medical Gas delivery will be provided by the respective Acute Trust under a service level agreement. Note at Halton Medical Gas cylinders to be used in NWBH areas are ordered by NWBH Estates Department. The cylinders are stored in a NWBH designated area on the Halton site and are delivered/returned by Halton Porters under a service level agreement. Once Medical Gas deliveries have been accepted at Warrington, Halton and Wigan sites, the delivery note must be sent to NWBH Estates Department to facilitate invoice payment.

5 Service Level Agreements

Where oxygen is provided under service level agreement (SLAs), the policies and storage protocols of the host trust must be followed.

SLAs for the supply & delivery of Medical Gases are available for Halton (the Brooker Centre), Knowlsey (Knowsley Resource & Recovery Centre) and St Helens (Peasley Cross).

6 Storage of Cylinders

The Estates Department will ensure that Medical Gas cylinders are stored under cover, kept clean, dry & well ventilated, and are not subject to extremes of temperature.

External Storage

Medical Gas cylinders must be kept in a purpose built cylinder store with warning notices prohibiting smoking and naked lights within the vicinity of the store. The storage area must be clearly signposted to ensure emergency services know the location in case of fire. These signs must be requested from the Estates Department. The Medical Gas storage area must allow a separate designated area for full and empty cylinders and permit a system for stock rotation of cylinders to enable the cylinders with the oldest filling date to be used first prior to its expiry date. The cylinder store must NOT be used for anything other than Medical Gas cylinders and cylinder trolleys and must be kept locked when not in use.

Page 7 of 36

Internal Storage

Medical Gas cylinders stored in wards/other clinical areas must be stored in a cylinder trolley conforming to BS2718. All Medical Gas cylinders must be stored safely to prevent them from accidentally falling over. Medical Gas cylinders must be checked routinely as part of the resuscitation equipment daily checks. If any defects are noted, a manager must be immediately informed and replacement must be arranged (see Appendix 2). All ward/clinical staff must know the designated location of the Medical Gas cylinders. Care must be taken to ensure cylinders/trolleys do not block doorways, fire exits etc. Medical Gas cylinders must be kept away from sources of heat and ignition (e.g. hot pipes and radiators), highly flammable or combustible materials. Internal Medical Gas cylinder storage areas must be kept clean, dry, well ventilated and not subject to extremes of temperature. There must also be a system in place for stock rotation and the segregation of full and empty cylinders. Warning notices must be displayed outside the internal area where gases are stored to alert the emergency services to the presence of Medical Gases in cases of fire. These signs must be requested from NWBH Estates Department. Large (HX or ZX) size cylinders must be stored vertically. Small (CD) size cylinders must be stored horizontally. All inpatient wards (units or areas) must have one large cylinder ‘in use’ with one reserve large cylinder that remains full until ‘in use’. The cylinder ‘in use’ and the reserve cylinder must be checked to ensure they are sufficiently full to meet the needs of the patient. Refer to local SOP’s/Resuscitation equipment log book for guidance of minimum fill levels.

7 Entonox

Storage of Entonox Cylinders

Entonox cylinders must be stored under cover, preferably inside, kept dry and clean.

Not stored near stocks of combustible materials.

Not subjected to extremes of heat and cold.

Stored separately from industrial and other non-medical cylinders.

Stored to maintain separation between full and empty cylinders.

Used in strict rotation so that cylinders with the earliest filling date are used first.

Stored separately from other medical cylinders within the store.

Page 8 of 36

F size cylinders and larger should be stored vertically.

D size cylinders and smaller may be stored horizontally.

To ensure that the gas is suitable for immediate use, Entonox cylinders should be maintained at a temperature above 10°C for at least 24 hours before use.

Warning notices prohibiting smoking and naked lights must be posted clearly in the cylinder storage area and the emergency services should be advised of the location of the cylinder store.

Precautions should be taken to protect cylinders from theft.

Use of Entonox Cylinders When Entonox cylinders are in use ensure that they are:

Only used for medicinal purposes.

Turned off, when not in use, using only moderate force to close the valve.

Only moved with the appropriate size and type of trolley or handling device.

Handled with care and not knocked violently or allowed to fall.

Firmly secured to a suitable cylinder support when in use.

Not allowed to have any markings, labels or batch labels obscured or removed.

Not used in the vicinity of persons smoking or near naked lights.

Used in a well ventilated area to maintain the average occupational exposure level of the healthcare professional to less than 100ppm (over an 8 hour period).

When the Entonox cylinder is empty ensure that the:

Cylinder valve is closed using moderate force only and the pressure in the regulator or tailpipe is vented

Valve outlet cap is replaced (where fitted)

Empty cylinders are immediately returned to the empty cylinder store for return to the designated supplier.

8 Preparation for Cylinders to be returned to store or to Medical Gas supplier

After use, the cylinder valve should be closed and any gas in the equipment must be safely vented to atmosphere and the equipment control valve closed. Cylinders that require replacement, are empty or those which are no longer in use, must be returned to the gas cylinder store as soon as possible. The segregation of full and empty cylinders must be undertaken at all times.

9 Signage

Areas where oxygen is stored must have a warning “Oxygen Storage” sign clearly displayed on the outside of the door. All vehicles used for the transport of Medical Gases must clearly display signage on the vehicle demonstrating that they have a specific carrier licence.

Page 9 of 36

For information on standard signage that should be used needs to be requested from NWBH Estates Department.

10 Transportation of Cylinders

A full risk assessment must be conducted for any tasks involving the transportation of Medical Gases by the manager, with assistance from the Trust Health and Safety Department if required. Staff involved in the transportation of Medical Gas cylinders must be provided with the appropriate information/training to ensure that Medical Gas cylinders are transported in a safe and appropriate manner. Staff responsible for moving cylinders around or across sites must ensure that a moving and handling assessment is completed in accordance with statutory legislation and the Trust Moving and Handling Policy and Procedures. Staff must wear PPE, i.e. industrial gloves and protective safety footwear when transporting large cylinders. All equipment (including hands/gloves) used to transport cylinders must be free from grease and oil. Cylinders are only transported on a cylinder trolley designed for the appropriate sized cylinder (BS standard 2718) and must be restrained properly using the crossbar or chain. Cylinders must never be rolled or propped up against a wall during transportation. Cylinders must not be transported in vehicles that do not comply with the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004 (the Carriage Regulations), as amended in 2005. Vehicles that transport oxygen should display a “No Smoking” sign. Only small size cylinders should be transported (horizontally) in a dedicated bag by road for emergency use in offsite clinics e.g. CD size. Small cylinders for emergency use in offsite clinics must be returned to base at the end of the working day. Large size cylinders must remain at base and not be transported to outside locations routinely.

Page 10 of 36

11 Unloading of Cylinders

Delivery vehicles hoists or tail loaders must be as clean as is practical and mechanical parts shielded in order to prevent contamination of cylinders with oil or grease.

12 Handling of Cylinders and Storage

Smoking and naked lights are prohibited in the vicinity of cylinders.

Cylinders must only be handled by personnel who understand the hazards involved and who have received appropriate training.

Cylinders should not be used as rollers or be permitted to strike together violently or be dropped.

Cylinders and valves must be kept free from oil and grease.

Cylinders must not be marked with chalk, crayon, paint or other similar materials, or by the application of adhesive tape. A tie-on label indicating the content state must be attached to the cylinder.

Heavy protective gloves (preferably textile or leather) and protective safety footwear must be worn when loading or unloading cylinder. The gloves, protective boots and overalls must be free from oil and grease.

Cylinders must always be secure during transportation and use.

Cylinders must not be painted or be otherwise obscured in a manner that prevents identification of their contents.

Care must be taken in order to preserve the cylinder labels and surface finish.

Alterations or modifications of gas cylinders must not be undertaken.

Markings used for identification of cylinder contents, pressure testing of cylinder, tare weight etc. must not be defaced or removed. This applies to labels transfers, tags and undertaken marks.

Cylinder valves must always be closed after use and when cylinders are empty.

Medical Gas cylinders must not be used for non-medical purposes.

13 Using Medical Gas Cylinders

The Trust only uses Medical Gas cylinders with integral heads. (Appendix 3). Check the cylinder labels to identify the contents (Name and Colour).

Medical Gas cylinder data chart

Check the gas pressure is in the approved range and the cylinder is within the printed expiry date. Visually inspect the cylinder for dents and bulges. If there are concerns arrangements must be made to collect the damaged equipment and for a replacement to be obtained. For local arrangements see respective SOP.

Page 11 of 36

The cylinder must be located in a safe position and secured so they cannot fall over. There must be no smoking or naked lights in the vicinity of the cylinder; nor should the cylinder be near an ignition source.

When using Medical Gas cylinders it is important that no part of the cylinder valve or equipment is either lubricated or contaminated with oil or grease. Special care is needed with the use of hand creams as they could provide sufficient contamination to the medical cylinder valve to cause ignition when the valve is turned on. Any sign of contamination or damage must be reported to the line manager immediately. The cylinder must be isolated and a replacement sought.

14 Cylinders Labelling / Markings

Cylinders must be marked and colour coded in accordance with BS 1319 and Packaging and Labelling of Dangerous Substances Regulations S1 No.1244. The general requirement of BS5724 Part 1 regarding stability should also be complied with. Each cylinder must have: -

The product license number.

A label to include each number, cylinder code, filling branch code and

product filling date and expiry date.

A hazard warning sign.

The name and chemical symbol of the gas or gas mixture contained in

the cylinder. In the case of gas mixtures, the proportion of the constituent gases must be shown.

A substance identification number.

The serial number.

Year and a quarter of test of cylinder.

Any specific product and cylinder handling precautions. o Particular instructions to the user where appropriate.

Cylinder pressure reducing regulators (where used) and pressure gauges must be conspicuously marked “Use No Oil or Grease” or with an appropriate symbol. Where appropriate, cylinder yokes, pressure reducing regulators and pressure gauges must be clearly and indelibly marked designating the gas or gas mixture for which they are to be used.

15 Returning Cylinders

After use, the cylinder valve should be closed and any gas in the cylinder head vented to atmosphere and the control valve closed.

Page 12 of 36

Once the Medical Gas cylinder is at level that requires changing, cylinders must be returned to the storage area and kept in the designated area for empty cylinders for the nominated supplier to collect. See the Locality SOP and resuscitation Log Book for relevant details. For oxygen cylinders contained within the LifeLine bags replacements are obtained direct from the nominated supplier. See the Locality SOP and resuscitation Log Book for relevant details.

16 Gas Leak Precautions

If a leak is suspected remove from clinical practice and quarantine the cylinder. Close the cylinder valve, vent the gas safely to the atmosphere and contact the Porters or nominated supplier. Under no circumstances must excessive force be used when closing valves as this may result in damage. If it is evident that a valve can only be operated using excessive force, it may indicate a faulty valve seal. This should be reported to the supplier and the cylinder should be removed from use and a ‘faulty’ label should be tied to the cylinder. Also cylinders with damaged or very stiff valves must be labelled appropriately and returned to the supplier. The detection of leaks must not be carried out using a lighted cigarette or other naked flame. A soapy water solution or proprietary leak detection fluid must be used. After use, it should be wiped off with a clean damp cloth in order to prevent possible corrosion. Sealing or jointing compound must not be used to remedy leaks. Any leakage, which cannot be correctly rectified on equipment, must be notified to the supplier. No attempt must be made to repair, alter or modify any cylinder or its valve.

17 Fire and Heat Precautions

Fire can occur when the following three conditions are present:

• Flammable materials • Oxidising atmosphere • Ignition

All cylinder stores should be free from naked flames and all sources of ignition and should be designated as “no smoking areas”. Appropriate fire-fighting equipment should be provided and the fire brigade notified of the location of stores and any emergency access keys. Smoke/heat detectors should also be installed in Medical Gas cylinder stores.

Page 13 of 36

18 Combustible Materials

The combustible materials which may be present near patients include skin lotions, cosmetic tissues, hair oils, some nail varnish removers, oil based lubricants, clothing, bed linen, rubber articles, plastic articles, alcohol’s (including alcohol rubs), acetone, skin preparation solutions and certain disinfectants.

19 Ignition Sources

Ignition sources include, lighted cigarettes/pipes, open flames, sparks (which may be produced by some children’s toys), high frequency and short-wave equipment, laser equipment, hair dryers, excessive temperature in electrical equipment and arcing. Ignition can also be caused by the discharge of a defibrillator. Other sources of ignition may include electrical equipment not specifically designed for use in an oxygen-enriched atmosphere. Ignition may also be caused by non-electrical equipment. For example, a static discharge, which may be created by friction, can cause ignition especially if easily ignited substances such as cyclopropane, alcohol (including alcohol rubs), acetone, some nail varnish removers, oils, greases or lotions are present.

20 Fire Precaution Guidance

Further guidance shall be obtained from the fire prevention officers, fire safety officers and the local fire brigade.

21 Other Fire & Heat Precautions Special precautions are required when administering flammable gas mixtures and flammable anaesthetic agents to patients. Mixtures of breathing gases will support combustion, materials not normally considered to be combustible and flammable in air ignite more easily and burn more vigorously in an oxygen or nitrous oxide enriched atmosphere. Clothing may become saturated with oxygen or nitrous oxide and constitute a fire risk. Clothing will become free from the enrichment of the gases after approximately 5 minutes in ordinary air. However blankets or other similar articles may need to be turned over several times in ordinary air in order to achieve the same result. Oil and grease must not be used as a lubricant on any gas cylinder or equipment due to when in the presence of high pressure oxygen or nitrous oxide; it is prone to spontaneous combustion. In particular, oil and grease must not be used on cylinder valves, couplings and regulators. Tools, hands and clothing must also be kept free from oil and grease.

Page 14 of 36

Cylinders must be kept away from sources of heat, such as sunny locations or proximity to steam pipes etc. When equipment is coupled to cylinders, the cylinder valve must initially be opened as slowly as possible. Rapid opening can create a sudden adiabatic increase in downstream gas pressure. The consequential rise in temperature may result in ignition of any combustible material coming into contact with the hot gas downstream, which could include the regulator valve seal.

22 Chemical Hazards

Oil, grease, bituminous products, acids and other corrosive substances must not be allowed to come into contact with Medical Gas cylinders and their associated equipment.

23 E-Learning

An eLearning training package is available on the intranet for staff to undertake. It is essential that staff familiarise themselves with the content within the training package before using Medical Gases. Staff also undertake mandatory manual handling training as part of Trust Induction.

24 Incident Reporting

The Trust’s Incident Reporting system must be used to report any incident or near miss relating to Medical Gases or any aspect or their management. Incidents reporting should cover both the clinical use and the safe handling of Medical Gases and cylinders. The NWBH Estates Department, Resuscitation Officer and Chief Pharmacist may be contacted directly if there are concerns regarding the safe handling of Medical Gas.

25 Records

Staff in Walk in Centres complete a daily check of emergency equipment including oxygen cylinders in accordance with the Resuscitation Procedure and WIC SOP. Ward based staff complete a daily check of emergency equipment including the oxygen cylinders in accordance with the Resuscitation Procedure and local SOP

Atherleigh Park SOP

Knowsley Resource and Recovery Centre SOP

Peasley Cross SOP

Halton (Brooker Centre) SOP

Hollins Park SOP.

Community sites complete a daily check of emergency equipment of emergency equipment including the oxygen cylinders in accordance with the Resuscitation Procedure and Community LifeLine SOP and resus procedure.

Page 15 of 36

All delivery notes and maintenance records must be retained. Records must be kept in accordance with the Records Management Policy. Record Keeping Policy

26 Monitoring of compliance with this procedure

Minimum requirements to be monitored

Process for monitoring

e.g. audit

Responsible individual, group or committee

Frequency of monitoring

Responsible individual, group or committee for review of results

Responsible individual, group or committee for development of action plan

Responsible individual, group or committee for monitoring of action plan

Safety of Equipment

Self-Assessment

Medical Devices and Equipment Group

Annually Medical Devices and Equipment Group

Medical Devices and Equipment Group

Health & Safety Committee

Provision and storage of cylinders

Self-Assessment

Medical Devices and Equipment Group

Annually Medical Devices and Equipment Group

Medical Devices and Equipment Group

Health & Safety Committee

Management of the Service Level Agreement for Medical Gasses.

Self-Assessment

Medical Devices and Equipment Group

Annually

Medical Devices and Equipment Group

Procurement Health & Safety Committee

Aggregated reports of incidents involving Medical Gases. (Datix reporting)

Reports received at meetings of the Medical Device Committee Meetings.

Medical Devices and Equipment Group

Ad Hoc following an incident

Medical Devices and Equipment Group

Medical Devices and Equipment Group

Health & Safety Committee

Staff complete daily checks and record are retained locally; including checking oxygen in date

Self-Assessment

Resuscitation

Group

Annually Resuscitation Group

Resuscitation Group

Resuscitation Group

Duties: ensuring staff receive appropriate training in accordance with requirements

This is monitored in line with the Trust Performance Report on Training

Physical Health Skills

Six monthly Resuscitation

Steering Group

Medical Devices and Equipment Group

Health &safety Cttee

Page 16 of 36

Servicing of relevant equipment

Self-assessment

Estates Annually Medical Devices and Equipment Group

Medical Devices and Equipment Group

Medical Devices and Equipment Group

27 References

NPSA Guidance - RRR006: Oxygen safety in Hospitals (September 2009)

http://www.google.co.uk/search?q=npsa+oxygen+cylinders&hl=en&gbv=2&rlz=1R2SUNA_enGB338&gs_l=hp.3...1015.21311.0.21811.39.16.0.16.1.0.453.2546.2-7j0j2.9.0...0.0.aHwYeSQSvoU&safe=active&oq=NPSA+oxygen+cylinders

BOC Medical Gas Data Sheet (MGDS), Medical oxygen -compressed gas. http://www.bochealthcare.co.uk/en/quality-and-safety/safety-and-technical-data/safety-data-sheets/safety-data-sheets.html

Health and Safety Executive - Oxygen Use in the Workplace – Fire and Explosion Hazards http://www.hse.gov.uk/pubns/indg459.htm BOC- ENTONOX ® Essential Safety Information http://www.bochealthcare.co.uk/en/images/HLC_505605-MGDS%20ENTONOX%20%28web%29_tcm409-57640.pdf

Health Technical Memorandum. HTM 02-01: Medical Gases: Medical Gas Pipeline Systems Part B: Operational Management ISBN: 0-11-322743-4,The Stationary Office 2006.

Health and Safety at Work Act 1974

Control of Substances Hazardous to Health (COSHH) Regulations 2002

Medicines Act HMSO 1988

NPSA. Rapid Response Report/ 2009/ RRR0006. Oxygen Safety in

Hospitals. 29 September 2009.

28 Associated documents

This policy should be used in conjunction with the following Trust Policies, all of which are available on the intranet.

Medicines Management Policy

Management of Health and Safety at Work Policy

Moving and Handling Policy

Management of Medical Devices Policy / Procedure

Page 17 of 36

Resuscitation Policy / Procedure

Incident Management Policy

Clinical Skills Policy

Incident Reporting and Management Policy

Payment of Travel and Expenses Policy

NICE CG95: Chest pain of recent onset: Assessment and Diagnosis of recent onset of chest pain or discomfort of suspected cardiac origin.

Records Management Policy (Record Keeping)

29 Reference

The following documents are considered appropriate for formulating the framework for defining activities with MGPS and Medical Gas cylinders.

Health Technical Memorandum. HTM 02-01: Medical Gases: Medical Gas Pipeline Systems Part B: Operational Management ISBN: 0-11-322743-4,The Stationary Office 2006.

Health and Safety at Work Act 1974

Control of Substances Hazardous to Health (COSHH) Regulations 2002

Medicines Act HMSO 1988

NPSA. Rapid Response Report/ 2009/ RRR0006. Oxygen Safety in Hospitals. 29 September 2009.

Appendix One: Tables (A,B,C) summarising responsibilities for Medical Gas stock checks, ordering & deliveries, etc

Table A: Summarising roles related to Medical Gases in Trust localities for in-patient mental health wards

Function Mental Health Services: In-Patient wards

Atherleigh Park Hollins Park Brooker Centre KRRC Peasley Cross

Stock check Ward staff Ward staff Ward staff Ward staff Ward staff

Stock requests are made by

Ward staff Ward staff Ward staff Ward staff Ward staff

Ward stock requests are made to

Local porters Local porters WHH porters StHKTH porters StHKTH porters

Ward stocks are delivered/returned by

Local porters Local porters WHH porters StHKTH porters StHKTH porters

Site stock is maintained by

Estates Estates WHH Porters & NWBH Estates

StHKTH SLA StHKTH SLA

Page 19 of 36

Table B: Summarising roles related to Medical Gases in Trust localities for out-patient & community mental health services

Function

Mental Health Services: out-patient & community teams

Halton Knowsley Peasley Cross

Warrington

Wigan & Leigh

Brooker Centre

St Johns Unit

KRRC Others All

community teams

Newton Community

Hospital

Wakefield House

All community

teams

Stock check Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Stock requests are made by

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Nominated team staff

Site staff

Ward stock requests are made to

WHH porters

Nominated supplier

StHKTH porters

Nominated supplier

StHKTH porters

HP Porters Nominated

supplier Nominated

supplier

Ward stocks are delivered/returned by

WHH porters

Nominated supplier

StHKTH porters

Nominated supplier

StHKTH porters

HP Porters Nominated

supplier Nominated

supplier

Site stock is maintained by *

WHH Porters & Estates

NA StHKTH

SLA NA

StHKTH SLA

HP Porters NA NA

Page 20 of 36

Table C: Summarising roles related to Medical Gases in Trust localities for physical health services

Function

Physical Health Services

Knowsley St Helens Sefton

WICs Other Other WIC Other

Ward stock check Nominated WIC

staff Nominated team staff

Nominated team staff Nominated WIC

staff Nominated team staff

Stock requests are made by

Nominated WIC staff

Nominated team staff

Nominated team staff Nominated WIC

staff Nominated team staff

Ward stock requests are made

to

Nominated supplier

Nominated supplier

Nominated supplier Nominated

supplier Nominated

supplier

Ward stocks are delivered/returned

by

Nominated supplier

Nominated supplier

Nominated supplier Nominated

supplier Nominated

supplier

Key: HP Hollins Park KRRC Knowsley Resource & Recovery Centre NA Not applicable StHKTH St Helens & Knowsley Teaching Hospitals NHS Trust SLA Service Level Agreement WHH Warrington & Halton Hospitals NHS Foundation Trust WIC Walk In Centre

Appendix Two

Page 22 of 36

Page 23 of 36

Page 24 of 36

Page 25 of 36

Checklist before connecting the regulator to the cylinder

The following checks must be performed before connecting the regulator to the cylinder to ensure:-

there is no damage to the ‘hand grip’

the inlet, including the threads, are clean and undamaged

the ‘O’ ring or sealing washer is in good condition

the gauges are in good condition, lenses attached and indicator reading zero

the flow meter is undamaged, suitable for the gas in the cylinder, the “ball” moves freely and that the flow adjusting screw turns freely. If not isolate the flow meter and return to the supplier as soon as possible

pressure relief devices are in good condition, have not been removed or blanked off

the flow meter is off/closed by unscrewing the control knob fully

the oxygen is in date. When the above checks have been completed and the regulator approved, it may be attached to the cylinder. If any damage is found the regulator should be isolated and returned to the supplier for replacement as soon as possible. Portable Emergency Oxygen Kits for Resuscitation contain an integral regulator. No attempt must be made to remove the regulator from the portable cylinder.

Connecting the Regulator to the Cylinder

Remove the protective cap from the cylinder. The regulator must be attached to the cylinder using only reasonable force to tighten. The cylinder valve must be opened slowly with a standard valve key or hand wheel. The valve must NOT be opened fully. The meter must be checked to ensure there is enough gas available for the required use. All connections must be checked for leaks once the system is pressurised. Check the valve for connection leaks. Connect the cylinder valve and note any fall in the regulator pressure gauge reading. The spindle key must be left in the valve so it may be closed in an emergency.

The cylinder must be checked for leaks daily. If you suspect a leak from an oxygen cylinder you should:

Page 26 of 36

turn off the oxygen supply immediately

make sure that the room is well ventilated

report the leak immediately and in accordance with local arrangements

make sure that there is a label on the cylinder marked “Faulty – Do Not Use”.

Contact Estates Leaks may occur between the valve outlet and the connected equipment, and may be indicated by a hissing sound. Having connected equipment cylinder it is good practice to check for leaks when the valve is open. Ensure the equipment operating instructions are available at all times.

After Use

After use, the cylinder must be closed immediately using a correctly designed cylinder valve key. The cylinder key must be removed from the valve. The pressure in the regulator must be released before removal. The protective cap must be replaced over the valve outlet to prevent contamination. Care must be taken not to vent the cylinders or leave them open. Oxygen cylinders should be replaced in accordance with local procedures (resuscitation checklist). If cylinders and/or masks need to be replaced follow the local arrangements in place.

Page 27 of 36

Appendix Three

Page 28 of 36

Page 29 of 36

Page 30 of 36

Page 31 of 36

Appendix Four

Page 32 of 36

Page 33 of 36

Appendix Five

Page 34 of 36

Page 35 of 36

Page 36 of 36