Medical Gases

Lynn MorrisonLynn Morrison

Regional QA PharmacistRegional QA Pharmacist

NHS Greater Glasgow and ClydeNHS Greater Glasgow and Clyde

Medical GasesIntroduction and session objectivesIntroduction and session objectives

To describe the different medical gases found within a To describe the different medical gases found within a hospitalhospital

To understand the design and construction of a To understand the design and construction of a medical gas pipeline system (MGPS)medical gas pipeline system (MGPS)

To be aware of the system of controls applied to To be aware of the system of controls applied to facilitate the safe and secure operation of a medical facilitate the safe and secure operation of a medical gas pipeline systemgas pipeline system

To understand the roles and responsibilities of key To understand the roles and responsibilities of key personnel involved in medical gasespersonnel involved in medical gases

To understand the role of the Quality Controller To understand the role of the Quality Controller (MGPS)(MGPS)

To have an awareness of medical gas testingTo have an awareness of medical gas testing To appreciate the role of the EDC pharmacist in an To appreciate the role of the EDC pharmacist in an

emergency situationemergency situation

Medical Gases – what gases are found in hospitals? OxygenOxygen Nitrous oxideNitrous oxide Medical AirMedical Air Surgical AirSurgical Air Oxygen / Nitrous oxide mixture 50:50 Oxygen / Nitrous oxide mixture 50:50

“Equanox” or “Entonox”“Equanox” or “Entonox” VacuumVacuum

What are the medical gases used for? Oxygen – used to sustain lifeOxygen – used to sustain life Medical air – used to drive ventilatorsMedical air – used to drive ventilators Surgical air – used to operate surgical toolsSurgical air – used to operate surgical tools Nitrous oxide – used in theatres for Nitrous oxide – used in theatres for

anaesthetic purposesanaesthetic purposes Equanox / Entonox – used as an analgesic, Equanox / Entonox – used as an analgesic,

home deliveryhome delivery

Vacuum - suctionVacuum - suction

What other gases could you find? Carbon dioxideCarbon dioxide Helium / oxygen mixturesHelium / oxygen mixtures Nitric oxideNitric oxide

What are these gases used for?What are these gases used for? Carbon dioxide – clinical and physiological Carbon dioxide – clinical and physiological

investigations investigations Helium/oxygen mixtures – respiratory assessment Helium/oxygen mixtures – respiratory assessment

and treatment e.g. COADand treatment e.g. COAD Nitric oxide – aids oxygen exchange in respiratory Nitric oxide – aids oxygen exchange in respiratory

distress conditionsdistress conditions

How are the gases supplied to the hospital? Oxygen – delivered as a liquid via a tanker to a Oxygen – delivered as a liquid via a tanker to a

liquid oxygen tank compound with vacuum liquid oxygen tank compound with vacuum insulated evaporators - VIEinsulated evaporators - VIE

Nitrous oxide – cylindersNitrous oxide – cylinders Medical air – cylinders or compressorsMedical air – cylinders or compressors Equanox / Entonox – cylindersEquanox / Entonox – cylinders Other gases – cylinders Other gases – cylinders

NHS Scotland - national contracts for supply of NHS Scotland - national contracts for supply of medical gasesmedical gases

Where are the gases stored?

Liquid Storage Tank with VIE – oxygen Liquid Storage Tank with VIE – oxygen Cylinder store – various gasesCylinder store – various gases Manifold rooms – e.g. medical air, nitrous oxide, Manifold rooms – e.g. medical air, nitrous oxide,

Equanox/ EntonoxEquanox/ Entonox Medical and surgical air compressor systems and Medical and surgical air compressor systems and

receiver tanksreceiver tanks

Other locations – e.g. ready use storesOther locations – e.g. ready use stores ambulances ambulances patient transportpatient transport

Oxygen tank – VIE tank

““Duty” tank and a “stand by” tankDuty” tank and a “stand by” tank Vacuum insulated evaporatorVacuum insulated evaporator Valve box (with test point)Valve box (with test point) Alarm panelAlarm panel Copper pipework – medical gas pipeline Copper pipework – medical gas pipeline

system - connecting tanks to the system - connecting tanks to the hospital pipeline systemhospital pipeline system

Oxygen tank and VIE

Oxygen tank – control panel

Cylinder store Visit the cylinder store on siteVisit the cylinder store on site Cylinder stores should be :-Cylinder stores should be :-

separate from other buildingsseparate from other buildings

no “naked flames”no “naked flames” clean, tidy, lockedclean, tidy, locked full cylinders should be stored separately from emptyfull cylinders should be stored separately from empty each gas type to be stored separatelyeach gas type to be stored separately etc etc Can you think of any other storage requirements?Can you think of any other storage requirements? separate cylinders by sizeseparate cylinders by size temperature controltemperature control log of issue and returnlog of issue and return

Cylinders Currently :-Currently :- Oxygen – black body / white shouldersOxygen – black body / white shoulders Nitrous oxide – blueNitrous oxide – blue Medical air – grey body / black and white shouldersMedical air – grey body / black and white shoulders Equanox / Entonox – blue body / blue and white Equanox / Entonox – blue body / blue and white

shouldersshoulders Heliox – black body / brown and white shouldersHeliox – black body / brown and white shoulders Carbon dioxide - grey Carbon dioxide - grey

Future :-Future :- EU Directive – all cylinders will have white body and EU Directive – all cylinders will have white body and

colour coded shoulders as abovecolour coded shoulders as above Implementation to be completed by 2025Implementation to be completed by 2025

Manifold rooms

A manifold is defined as a set of A manifold is defined as a set of pipework to which a series of cylinders pipework to which a series of cylinders is attached.is attached.

““Duty” and “stand by” bulk supply to the Duty” and “stand by” bulk supply to the hospitalhospital

Must be in dateMust be in date Must be checked regularlyMust be checked regularly

Oxygen manifold

Medical air manifold

Medical / Surgical air compressors

How do the gases get to the patient ? Medical Gas Pipeline System (MGPS)Medical Gas Pipeline System (MGPS) Copper pipelinesCopper pipelines Pressure reducing valvesPressure reducing valves AVSU – area valve service unitAVSU – area valve service unit Terminal outletsTerminal outlets Flow meter and tubingFlow meter and tubing Mask / nasal canulaeMask / nasal canulae

Cylinders – valve and flowmeterCylinders – valve and flowmeter

Area Valve Service Units

Terminal Units

Safety issues

Medical gasesMedical gases Oxygen – supports combustion – patient’s Oxygen – supports combustion – patient’s

clothing and bedding can become saturatedclothing and bedding can become saturated Nitrous oxide – causes headaches, Nitrous oxide – causes headaches,

drowsiness, cumulative effects, teratogenic drowsiness, cumulative effects, teratogenic effects, can cause asphyxia in confined effects, can cause asphyxia in confined spacesspaces

also supports combustionalso supports combustion Equanox / Entonox – combination of the Equanox / Entonox – combination of the

aboveabove

Safety issues

Cylinder handlingCylinder handling Never carry a cylinder by its neckNever carry a cylinder by its neck Use correct trolleysUse correct trolleys Protective equipmentProtective equipment Never roll cylinders!!Never roll cylinders!! Never eat/smoke while handling cylinders Never eat/smoke while handling cylinders Etc!!Etc!! Training vital!!!Training vital!!!

Control systems - Documentation HTM 02-01 HTM 02-01 Part A ;Part A ; Design, installation, Design, installation,

validation and validation and verificationverification

Part B ;Part B ; Operational Operational

ManagementManagement

In Scotland (s)HTM In Scotland (s)HTM 02-0102-01

Control systems - Documentation Permit to work system Permit to work system controls any engineering work to be carried out on the MGPScontrols any engineering work to be carried out on the MGPS

safeguards the integrity of the MGPS and patient safetysafeguards the integrity of the MGPS and patient safety 4 part documentation signed by all those involved in the work 4 part documentation signed by all those involved in the work

activity activity

Operational policiesOperational policies Controlled documentControlled document ScopeScope Responsibilities and training for staffResponsibilities and training for staff Record drawings and accompanying documentationRecord drawings and accompanying documentation Description of MGPS, valves, alarms etcDescription of MGPS, valves, alarms etc Medical gas committeeMedical gas committee Emergency proceduresEmergency procedures

Control systems - Documentation

Health and Safety at Work legislationHealth and Safety at Work legislation Manufacturer / supplier product Manufacturer / supplier product

material safety data sheets material safety data sheets C11C11 CHIPCHIP

SPQAG testing protocolsSPQAG testing protocols

Control systems – defined roles and responsibilities

Designated Medical Officer or Designated Medical Officer or Nursing OfficerNursing Officer

Authorised PersonAuthorised Person Competent PersonCompetent Person QUALITY CONTROLLER QUALITY CONTROLLER

(MGPS)(MGPS)

Control systems – defined roles and responsibilities

QUALITY CONTROLLER (MGPS)QUALITY CONTROLLER (MGPS) responsible for the quality control of medical responsible for the quality control of medical

gases as terminal units and plantgases as terminal units and plant accepts professional responsibility for the accepts professional responsibility for the

last independent check of a MGPSlast independent check of a MGPS must be able to provide evidence of training, must be able to provide evidence of training,

competencecompetence registered - QC (MGPS) registerregistered - QC (MGPS) register

Your involvement with medical gases

Clinical function Clinical function Clinical needClinical need EquipmentEquipment

Understand operation of MGPSUnderstand operation of MGPS Understand safety considerations for cylindersUnderstand safety considerations for cylinders Regulators, flowmeters and associated tubing Regulators, flowmeters and associated tubing

etcetc

Emergency situations Must be aware of day to day operational Must be aware of day to day operational

aspects of MGPS / cylinder management to aspects of MGPS / cylinder management to ensure have fundamental knowledge to cope ensure have fundamental knowledge to cope with emergency situationwith emergency situation

ExamplesExamples

Procedure to be followedProcedure to be followed

Operational policy documents and Operational policy documents and emergency information cardsemergency information cards

Emergency situations YOUR ROLE YOUR ROLE to ensure back up supply is made available and to ensure back up supply is made available and

additional cylinders sourced as required additional cylinders sourced as required to contact suppliers and arrange delivery to contact suppliers and arrange delivery

Must ensure you know :-Must ensure you know :- where back up supply (cylinders / tank) stored on sitewhere back up supply (cylinders / tank) stored on site how to contact suppliers (cylinders or liquid supply)how to contact suppliers (cylinders or liquid supply) how many cylinders to ask forhow many cylinders to ask for the size of cylinder to ask forthe size of cylinder to ask for the delivery locationthe delivery location BEFORE AN EMERGENCY OCCURS !!BEFORE AN EMERGENCY OCCURS !!

Medical gases

TestingTesting

Medical gas testing

RQAS Med Gas test teamRQAS Med Gas test team

Tests carried out – commissioning new installationsTests carried out – commissioning new installations modifications to existing systemsmodifications to existing systems de-commissioning of systemsde-commissioning of systems routine compressor testingroutine compressor testing

Medical gas testing Tests completed Tests completed Identity / purityIdentity / purity Particulate contaminationParticulate contamination Non specific contaminationNon specific contamination Water vapourWater vapour Carbon DioxideCarbon Dioxide Carbon MonoxideCarbon Monoxide OilOil Sulphur dioxideSulphur dioxide Nitrous fumesNitrous fumes Line pressureLine pressure

Vacuum pressureVacuum pressure

Acceptance criteria (Ph. Eur.) Identity and purity – acceptance criteria Identity and purity – acceptance criteria oxygen - > or equal to 99.5% oxygen - > or equal to 99.5% (absence of nitrous oxide)(absence of nitrous oxide) oxygen in medical / surgical air – oxygen in medical / surgical air – 20.4% to 21.4%20.4% to 21.4% nitrous oxide - >98%nitrous oxide - >98% (absence of oxygen)(absence of oxygen) oxygen / nitrous oxide mixture oxygen / nitrous oxide mixture 48% to 52% of each component48% to 52% of each component Particles – absence of particles e.g. copper oxide, copper, Particles – absence of particles e.g. copper oxide, copper,

“verdigris”“verdigris” Non- specific contamination – polytest tube – absence of Non- specific contamination – polytest tube – absence of

colour change in crystalscolour change in crystals Water vapour – not more than 0.05mg/L / 67vpmWater vapour – not more than 0.05mg/L / 67vpm

Acceptance criteria (Ph. Eur.) CO2 – not more than 500ppm / 300ppmCO2 – not more than 500ppm / 300ppm CO – not more than 5ppmCO – not more than 5ppm Oil – not more than 0.1mg/L – medical / Oil – not more than 0.1mg/L – medical /

surgical air to ensure no carry over from surgical air to ensure no carry over from compressor motorscompressor motors

Sulphur dioxide – not more than 1ppmSulphur dioxide – not more than 1ppm Nitrous fumes – not more than 2ppmNitrous fumes – not more than 2ppm

Vacuum – not less than 400mmHgVacuum – not less than 400mmHg

Visit to Medical Gas storage facilities and wards/ departmentsVisit the following :-Visit the following :- Oxygen tank and VIE plantOxygen tank and VIE plant Medical air compressor plantMedical air compressor plant Nitrous oxide manifoldNitrous oxide manifold

Visit a ward :-Visit a ward :- What gases are supplied via a piped system? What gases are supplied via a piped system?

- look out for terminal units, area valve service units - look out for terminal units, area valve service units (AVSU)(AVSU)

What gases are supplied in cylinder form?What gases are supplied in cylinder form?

Quiz

Please complete multiple choice Please complete multiple choice questionsquestions