1

FUNCTION

1.1

To ensure that medical gases in cylinders are handled, stored, transported, administered, and maintained safely within all hospitals and departments of NHS Fife and all non-NHS Fife settings where NHS Fife staff store or administer Medical Gas.

2

LOCATION

2.1

Within all NHS Fife properties and all non-NHS Fife settings where NHS Fife staff store, transport or administer medical gases.

3

RESPONSIBILITY

3.1

Local Responsibility

Medical Gases shall be considered as medicinal products under the provision of the Human Medicines Regulations 2012 and should be afforded the appropriate degree of control as with other medicinal products within the meaning of this Act.

If therefore, a medical gas such as oxygen is prescribed for an inpatient it must be prescribed on a medicine’s Kardex by a medical practitioner (NHS Fife Safe and Secure Use of Medicines Policy and Procedure).

3.1.1

There must be a designated person assigned at each gas store who has responsibility for ordering, distributing and managing stocks of medical gas cylinders.

3.1.2

Staff handling cylinders must be trained in those areas of responsibility outlined in this procedure, e.g. in the use and handling of cylinders, cylinder trolleys and in the fitting of equipment to cylinders. This is a mandatory requirement and should be undertaken as highlighted in NHS Fife Medical Gas Policy (GP/M3), Section 4, Table 2 – ‘Training Schedules for Staff Working with Medical Gas Cylinders’.

3.1.3

It is the responsibility of the Senior Charge Nurse / Department Head to ensure all staff handling medical gas cylinders are appropriately trained in accordance with NHS Fife Medical Gas Policy GP/M3.

4

OPERATIONAL SYSTEM

4.1

STOCK CONTROL

Good stock control and handling ensures that the correct cylinders are received for use which are in good condition, and have a reasonable shelf life; and that unnecessarily large stock holdings of either full or empty cylinders is avoided. Excessive stock holdings attract unnecessary rental charges.

4.2

Ordering and Returns to Suppliers for Medical Gas Stores within Office Hours

A regular check of stockholding should be made, taking into account usage at the time and when the need to order medical gases is identified you should pass the following information on to your designated ordering officer:

• The medical gas required and cylinder size
• The number of cylinders required
• The number of empty cylinders to be returned

This information is essential as the medical gas cylinder contractor operates a one for one system, where the number of cylinders to be returned should equal number of cylinders ordered.

4.3

All medical gases in cylinders are ordered by the Purchasing Team, Pharmacy Department, Victoria Hospital, Kirkcaldy.

Orders must be placed no later than 12 noon on the day before the order is required by email to:

fife-uhb.pharmacyprocurement@nhs.netor by  phoning VHK extension 28050 /28021

4.4

RESPONSIBILITIES OF PHARMACY ORDERING OFFICER

4.4.1

The ordering officer should place the order no later than 4pm on the day the order is received.

The Pharmacy Governance Team and either Ward / department/ porters / shift supervisors,  as appropriate, must be advised by the purchasing team immediately of any of the following:

• Any delay
• Any shortages – with alternatives if available
• Other relevant information

Orders should be placed with the medical gas contractor to comply with the agreed delivery schedule.

4.5

OUT OF HOURS/EMERGENCY DELIVERY

4.5.1

Ordering medical gases outside normal office hours should be avoided unless absolutely necessary, i.e. where gas supply may be insufficient to meet potential demand. In the first instance an alternative supply should be sought from another site. Appendix A – Approximate Duration of Use of Cylinders, shows average length of time a cylinder will take to go from full to empty at a variety of flow rates.

4.5.2

Medical gas cylinders can only be transported across sites using designated vehicles which have been fitted with appropriate racking and transported in accordance with Section 4.14 of this procedure.

4.5.3

If an emergency order has to be placed, approval must be given by the manager of the service. The

following information must be provided to the medical gas supplier (BOC)

• Site address (and code if possible)
• Name of ordering officer
• Type of gas required
• Number of cylinders required and size
• Time scale (when you need the delivery by)

Please note: an additional charge is made for emergency supply. Monday – Friday between 9am-5pm           £260+VAT + standard delivery charge

Weekends and Out of Hours £310+VAT + standard delivery charge.

BOC 24 hour order helpline 0800 111 333

4.5.4

The Pharmacy Purchasing Team must be contacted as soon as possible to inform them that an out-of-hours order was placed, and the details of the order provided. The ordering officer should then complete an official order form and send it to the medical gas supplier as soon as possible, but should also phone the supplier to confirm the official order number.

4.6

ISSUES FROM STORES

4.6.1

A written procedure must be in place at each site detailing the system by which cylinders are requisitioned for use.  A record of issues must be kept on the approved NHS Fife form (appendix B- Medical Gas Cylinder Supply / Return Form). This should include the name of gas, size of cylinder, date of issue, number of cylinders issued, ward/department or name of recipient, batch number (which can be found on cylinder neck) and expiry date.

4.6.2

On receipt of the full cylinder(s) in wards and departments ensure that the valve has a protective cover (these are occasionally dislodged during transport). Check that the cylinder has a label and that you have been issued with the correct medical gas and size of cylinder(s). If the cylinder appears to be leaking or damaged, arrange for return to the cylinder store, ensuring that the cylinder is stored in a well ventilated location until this can be done.

4.7

RETURNS TO STORES

4.7.1

4.7.2

Empty or unused cylinders should be returned to the main store as soon as possible for return to the supplier.

Remember to leave a residual pressure in the cylinder - see section 4.14.13

Return of potentially contaminated cylinders:

• Where a medical gas cylinder is suspected of or is visiblycontaminated by blood, faeces, pus or any other bodily fluids, the cylinder must be isolated on the returning ward / department.
• It must be cleaned with warm water to remove as much solid or fluid contamination as possible and must be left to dry.
• Do not use any proprietary cleaning agents as these may damage the valve or cylinder.
• Once dry each cylinder must be placed in a special ‘contaminated’ bag which is supplied through BOC and can be made available by contacting Shift Leader.  The bag must be secured with a cable tie and returned to the hospital medical gas store.
• NHS Fife Purchasing Team, Pharmacy VHK, must be notified that a contaminated cylinder is ready to uplift, the Pharmacy BOC will notify BOC on 0800 111 333 to make a suitable arrangement for collection. This information must be fed back to Lead Porter / Shift Leader.

4.8

ROTATION OF STOCK

4.8.1

It is the responsibility of the designated person at each main store to ensure that stock is rotated regularly, and that stock is managed on a ‘first in first out’ basis i.e. stock with the shortest expiry used first.

4.9

STORAGE IN MEDICAL GAS STORE

4.9.1

The store must only be used for the storage of medical gases. New medical gas stores must be purpose built and comply with Scottish Health Technical Memorandum (SHTM) 02-01.

4.9.2

Cylinders must be kept in a store that is locked at all times and is under the control of a designated person to prevent unauthorised entry and to protect cylinders from theft.

4.9.3

The medical gas store must be under cover to protect cylinders from the elements and should not be subjected to extremes of temperature and/or weather e.g. direct sunlight, rain.

4.9.4

The gas store must be well-ventilated to provide cross-flow ventilation by top and bottom ventilation openings to minimise the possibility of gas accumulating in the event of a leak.

4.9.5

Good access must be available for delivery vehicles.

4.9.6

Safety signage in accordance with the requirements of the Health & Safety (Safety Signs & Signals) Regulations 1996 and the Health & Safety at Work Act 1974 must be posted outside all medical gas stores including a notice detailing contact details of the key holder for use in the event of emergency action. Appropriate signage must be displayed outside and inside the store including: No Smoking, full & empty, different cylinder types. Information and advice on obtaining the appropriate warning signs for gas stores can be obtained from Estates.

4.9.7

The store must be fitted with adequate lighting.

4.9.8

The store must allow for segregation of full and empty cylinders. The store must also permit segregation of different gases, particularly oxygen and flammable gases.

4.9.9

The store must be kept clean and dry and sited away from storage areas containing highly flammable liquids, combustible materials and sources of heat and ignition. Rubbish and debris should not be allowed to accumulate in the vicinity of the store.

4.9.10

Cylinders must be stored in suitable racks; racks for storing cylinders horizontally should be of metal construction. Cylinders size F and above must be stored vertically. Cylinders size E and below must be stored horizontally. Cylinders must always be secured and not left free standing.

4.9.11

Cylinders must not be marked with chalk, crayon or other material or by the application of adhesive tape/labels. A tie-on label indicating the content may be attached to the cylinder.

4.9.12

Under no circumstances should grease or lubricants be used on any part of the cylinder or valve. Remember grease or a lubricant may not be black, and may not be easily seen.

4.9.13

There are special storage and handling conditions for 50% Nitrous Oxide/ 50% Oxygen – (Equanox/Entonox) - see Appendix C

4.10

STORAGE IN WARDS / DEPARTMENTS

4.10.1

Storage of cylinders in wards or departments must be kept to a minimum. The area must be well ventilated and preferably in a non-public area.  Appropriate signage must be displayed.

4.10.2

All medical gas cylinders must be secured in appropriate trolleys at patient’s bedside.

It has been agreed in NHS Fife that G or G4C size cylinders will not be used except where ZX cylinders are unavailable.

If G and G4C cylinders are required they must be stored and used in trolleys which must additionally be secured by a chain or fitment to prevent the cylinder from falling over; alternatively a stabilised trolley can be used. 

4.10.3

Any used cylinder must be returned to the medical gas store as soon as possible. This is to reduce the number of cylinders held at ward/dept level and to allow a timely replacement of empty cylinders, which reduces the numbers of cylinders in total requiring to be rented by NHS Fife.

4.11

HANDLING AND MAINTENANCE OF CYLINDERS AND REGULATORS

Additional information for all medical gas types used can be found at Appendix C.

4.11.1

Personnel handling medical gas cylinders must be suitably trained in moving and handling medical gas cylinders and training must be in line with current manual handling regulations.

The following precautions must be followed:

• It is good practice to wear safety shoes and clean gloves when moving cylinders.
• Cylinders must only be moved with a trolley designed for appropriately sized cylinders. These trolleys must be kept clean and free from grease and oil and be reserved for the transportation of gas cylinders. Precaution must be taken to prevent cylinders from falling from the trolley. Trolleys must conform to BS 2718.

• Cylinders must be handled with care, never knocked violently or allowed to fall over.
• Cylinders must never be rolled along the ground or used as a means for rolling heavy objects as this may cause the valve to open accidentally or break. It may also damage the cylinder, its label and paint work.
• Do not remove valve seal from cylinder until cylinder is ready for use.
• Cylinders must not be lifted by the cap or valve. Cylinders are fitted with lifting lugs for this purpose.
• Smoking and naked lights are prohibited while handling cylinders.

4.11.2

All cylinders in wards/departments must be checked for the following on a weekly basis, and this check must be recorded by the ‘nominated person’:

• The expiry date of the medical gas cylinder(s).
• That the quantity of gas remaining in the cylinder is adequate for its purpose, and the cylinder returned to store for replacement before the cylinder becomes totally empty.
• Any suspected leaks – both cylinder and regulator (action must be taken)

4.12

REGULATORS

4.12.1

All medical gas regulators must be identified and included on a routine schedule for servicing by NHS Fife Pharmacy or Medical Physics.

Those fitted to equipment such as anaesthetic machines must be tested and serviced during the equipment servicing. Testing (between major services) must be carried out every six months, only by competent and trained staff, using only replacement parts supplied by the manufacturer. The six monthly tests must include a pressure test and inspection of good condition. This testing must be documented and records held by each department.

4.12.2

Regulators must either be serviced by the manufacturer or replaced every four to five years to ensure their continued suitability for use.

Evidence has shown that either inadequate or poor servicing of medical gas pressure reducing regulators introduce explosive, fire, and mechanical risks which have resulted in injury to both patients and users and also caused damage to equipment and property.

Staff in Victoria Hospital & Queen Margaret hospital must inform Medical Physics, staff in Community Hospitals must inform Pharmacy services at least one month in advance if they any regulator that will shortly expire.

4.12.3

A new type of cylinder is now available that has an integral regulator which does not require changing, testing or replacement. This is done by the gas company when the cylinders are returned after use. These cylinders contain more medical gas than conventional cylinders and are under a higher pressure.  Staff must ensure that any cylinder is returned to the medical gas store and is replaced on or before it expires.

4.13

GUIDELINES FOR THE USE OF OXYGEN CYLINDERS IN RESUSCITATION KIT BAGS / RESUS TROLLEYS

4.13.1

Important:

To ensure sufficient oxygen in an emergency please replace any:

• D  size cylinder  as soon as possible after any use.
• CD size cylinder before it is less than half full.
• E size cylinder before it is less than half full.
• ZX size cylinder when it is between a half and a quarter full

4.13.2

It is good practice, to keep a second reserve cylinder in the ward / department to replace the emergency oxygen cylinder in a resus bag or trolley.

4.13.3

It is the responsibility of staff in those areas which have resuscitation kits in bags or on trolleys to inform portering staff immediately when an emergency cylinder is required to replace a used one.

4.13.4

Where the resus bag or trolley is in a location out with an NHS Fife Hospital site e.g. a health centre, a member of staff should contact the porter/ shift leader of the nominated hospital to be supplied with or collect a replacement cylinder from the holding store. Once an exchange has been made the used cylinder should then be returned to holding store - Please refer to section 4.14 for transportation guidelines’

4.14

TRANSPORTATION

4.14.1

Staff transporting medical gas cylinders in their own car:-

If a member of staff is transporting oxygen or oxygen 50%/ nitrous oxide 50% in their own vehicle, it is their responsibility to ensure that they are insured to carry this out and this must be included in their annual driver declaration.  Only oxygen / oxygen50%/nitous50% size C, D, CD,ED cylinders should be transported by staff in their own vehicles and this should not be a routine requirement.

4.14.2

Transport in NHS Vehicles:

 Appropriate racking must be fitted in NHS Fife vehicles used to transport cylinders to secure the cylinder during transit

4.14.3

Cylinders must be transported in vehicles in a secure manner, ideally in an upright position to prevent injury in the event of an accident.

4.14.4

Driver (and passengers if appropriate) must know and understand the hazards from the medical gas.

4.14.5

Smoking is NOT permitted in any vehicle during transit.

4.14.6

Cylinders and regulators must be switched off and checked for leaks prior to transit, i.e. check for obvious signs such as hissing.

4.14.7

The valve cover of a new cylinder must be in place during transit.

4.14.8

Where possible cylinders must be stored out of direct sunlight and out of sight of passers-by.

4.14.9

In passenger vehicles cylinders should be transported in the boot of vehicle and not the passenger space unless in actual use.

4.14.

10

If cylinders are carried in the passenger compartment, they need to be appropriately secured to avoid damage or injury. The window should be partially open to allow adequate ventilation in the event of a leak.

4.14.

11

No more than 2 cylinders should be carried at one time except for emergency response teams.  Different types of gases should not be carried at the same time unless they are of the same hazard category e.g. both oxidising & asphyxiant gases

4.14.

12

Although not a legal requirement for small quantities of medical gases, a vehicle TREM card should be carried in the vehicle, as a matter of good practice, when transporting medical gases. These are available from Pharmacy Services, (01383 565347). Staff must familiarise themselves with the details of the emergency procedure before setting off. Additional signage for the outside of the vehicle is not necessary for the carriage of one or two cylinders. Further guidance on the transport of medical gas cylinders can be found in the HSE/DOT document “Working with ADR”.

4.15

Preparation of Cylinder for Use

4.15.1

The member of staff administering a medical gas must be satisfied as to the identity of the gas before use and that the correct cylinder size has been selected. The expiry date should also be checked before use.

4.15.2

Valve covers must be completely removed. Cylinder and equipment connection interfaces and their washers, or “O” ring seals, must be inspected, where appropriate, to make sure that they are in good condition. No more than one sealing washer should be used at each interface.

4.15.3

Cylinders must only be used with equipment designed for use with that particular cylinder type.

4.15.4

Cylinders containing liquefied gas e.g. nitrous oxide or carbon dioxide must only be used in the upright position.

4.15.5

A check must be made to ensure that the valve and cylinder is free from grease, oil and other lubricants.

4.15.6

Ensure that hands are clean and free from grease or residue from alcohol gels etc.

4.15.7

Where a regulator is required, connect the cylinder to the regulator/equipment and tighten firmly, do not use excessive force.

4.15.8

On cylinders that have integrated valves the content gauge is live even when the cylinder is switched off.

It is extremely important to make sure the cylinder is turned on and off at the ‘hand wheel’ as well as at the regulator flow valve.

Failure to do this has led to patient’s not receiving essential oxygen.

See Patient Safety Alert NHS/PSA/W/2018/00

4.15.9

Prior to opening the cylinder valve ensures the regulator / equipment valves are closed (at zero setting).

4.15.10

Open all cylinder valves slowly. When fully opened, close a quarter turn to enable subsequent user(s) to distinguish between an open or closed valve.  Under no circumstances should a spanner or any other tool be used to open or close hand wheel operated valves.

4.15.11

Ensure no leaks are present at any of the junctions between the cylinder valve and equipment.  This may generally be determined by a hissing sound or alternatively you may close the cylinder valve and verify the leak by noting any fall in the regulator pressure gauge reading. If a leak is identified between the cylinder valve and equipment it may be remedied by carefully tightening the connection. If the leak persists turn off the cylinder valve, vent any gas safely to atmosphere and detach the cylinder from equipment.

4.15.12

Do not use excessive force on valves or nuts as this may damage thread and valve seats. Sealing or jointing compound should not be used to remedy leaks.

Faulty Cylinder

4.15.13

Any cylinder found to be faulty should be labelled as such and returned via the porters to the medical gas store. Faulty cylinders must be reported to the supplier and the NHS Fife Pharmacy Purchasing team and then returned to the supplier in accordance with their procedures (see local guidance at medical gas store).

4.15.14

When the cylinder is not in use, the cylinder must be switched off by firstly turning off the regulator/equipment, then turning off the cylinder. Residual gas remaining within the regulator / equipment should be safely vented to the atmosphere by the simple action of opening the flow control valve and allowing the gas to empty out. This prevents the serious risk posed by a build up of pressure in the regulator that can lead to damage or failure of the regulator, leading to explosion and potential injury.

CYLINDERS MUST NOT BE COMPLETELY EMPTIED UNDER ANY

CIRCUMSTANCES.

4.15.15.

You must change D, E, F & G cylinders immediately after the contents gauge drops into the red zone, before the flow of gas stops due to the cylinder being empty. This is important to stop contamination from water or moisture entering the cylinders.The blue cap must be replaced on cylinder (F, G) after discontinuation of use.

Cylinders with integral valves e.g. CD, ZX, ZD etc. must be changed before the needle on the gauge enters the black section after the red area.

Additional information for emergency resuscitation equipment see section 4.13

4.16

HEALTH & SAFETY ISSUES

Note: In the event of a fire or explosion instigate the local fire alert procedure

4.16.1

No attempt should be made to examine, use, or tamper with the valve of a cylinder after it has been involved in an incident. Contact NHS Fife Health and Safety Team or medical gas supplier immediately for advice.

4.16.2

FIRE

• The occurrence of a fire requires the presence of combustible or flammable materials, an atmosphere containing oxygen, nitrous oxide or other oxidising agents and a source of ignition.  Combustible material may be unavoidably present when medical gases are being used. Ignition sources are avoidable.

• Examples of combustible materials which may be found near patient include: hair oils, some nail-varnish removers, clothing, bed linen, certain disinfectant and skin preparation solutions including alcohol based hand disinfectants, and hand creams.
• Examples of sources of ignition: Open flames, cigarettes (including e-cigarettes), anything which may produce a spark, laser equipment, short wave radio, hair dryers, and children’s toys which may give rise to sparking, excessive temperatures in electrical equipmentThe discharge of a cardiac defibrillator may also serve as a source of  ignition.
• Mixtures of breathing gases will support combustion. In an oxygen or nitrous oxide enriched atmosphere, material not normally considered to be combustible may be so, and materials that are combustible and flammable in air ignite more easily and burn more vigorously. Clothing may become saturated with oxygen or nitrous oxide and constitute a fire risk, Clothing and uniforms exposed to these gases will be free from enrichment of the gases after about five minutes in ordinary air.

4.16.3

In the event of a fire medical gas cylinders must be left in the ward / department / building if it is evacuated.  The patient must be taken to an appropriate area where administration of their medical gas can be re-established.

4.16.4

Staff must inform attending fire wardens and fire brigade personel of the exact location of any medical gas cylinders in their ward/ department.

4.16.4

Chemical Hazards

Cylinders and their associated equipment should be protected from and not come into contact with oil, grease, bituminous products, acids and other corrosive substances.

4.17

CONTACT DETAILS – see appendix D

5

RISK MANAGEMENT

5.1

Risk Assessment

If you have any concerns about the storage, transportation, handling, or use of medical gas cylinders, or if you feel that your work environment has been compromised, please inform your local ward/department risk assessor to carry out a review of the current risk assessment of the area in question. Due to the nature of the risk assessment the assessor should always contact the Division Health & Safety Advisor for guidance.

If you require advice or guidance please contact the fire officer or health and safety officer or Pharmacy at Lynebank Hospital.

5.2

Additional Note for Community Nursing Staff

Dolby Vivisol supply oxygen to all community patients in Fife. They are responsible for ensuring patient have been trained in all necessary aspects of health and safety and understand how to use their equipment. In the event of any problems arising with the patients supply, Dolby Vivisol should be contacted via their 24 Hour helpline – 0800 833531. However, any NHS Fife staff member who is working in an environment where medical gases are present must be aware of the health and safety issues contained in this document and must attend medical gas training as outlined in section 4 of the NHS Fife Medical Gas Policy.

6.

RELATED DOCUMENTS

6.1

Appendix A - Approximate duration of usage for typical ward size oxygen cylinders chart

6.2

Appendix B – Medical Gas Cylinder Supply / Return Form

6.3

Appendix C- Additional Information per gas type chart.

6.4

Appendix D – Useful Contact Information

6.5

NHS Fife Safe and Secure Use of Medicines Policy and Procedures.

6.6

GP/M3, NHS Fife Medical Gas Policy

6.7

GP/M3-2, NHS Fife Medical Pipeline Procedure

6.8

GP/M3 -3, NHS Fife Safe Storage Use and Transport of Liquid Nitrogen

7

REFERENCES

7.1

Medical Gas Site Safety and Security, BOC Healthcare(2010)

7.2

Code of Practice, Medical Gas Cylinders, HIE (1987)

7.3

Medical Cylinder Gas Cylinder Data Chart , BOC (2012)

7.4

Scottish Drug Tariff, Scottish Executive Health Department (April 2018)

7.5

British Dangerous Good Regulations CDG TPE (April 2012)

7.6

Scottish Health Technical Memorandum 02-01 – Medical Gas Pipeline Systems (2012)

7.7

British Standard 2718:1979, Specification for Gas Cylinder Trolleys

7.8

Patient Safety Alert NHS/PSA/W/2018/00

 7.9

7.10

7.11

7.12

7.13

Working with ADR – HSE/ Dept. of Transport (2004)

Human Medicines Regulations, 2012.

Safety (Safety Signs & Signals) Regulations 1996.

The Health & Safety at Work Act 1974

HSE/DOT document “Working with ADR”.

7.14

NHS Fife Safe and Secure Use of Medicines Policy and Procedures