- Salford Royal NHS Foundation Trust

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- Salford Royal NHS Foundation Trust
Operational policy for the management of
medical gas pipeline systems and
medical gas cylinders
Classification: Policy
Lead Author: Bill Lundy – Senior AP Medical Gases
Additional author(s): Mark Stapleton – Operational
Services Manager; Stephen Bewley – Chief Pharmacy
Technician
Authors Division: Clinical Support Services and
Tertiary Medicine
Unique ID: TWGFac1(12)
Issue number: 2
Expiry Date: October 2016
Contents
Who should read this document? ......................................................................... 3
Key Messages ........................................................................................................ 4
Background & Scope.............................................................................................. 4
What is new in this version? .................................................................................. 4
Policy/ Guideline/ Protocol ..................................................................................... 4
1. Exclusions ................................................................................................. 4
2. The MGPS structure ................................................................................. 4
3. Gases Provided through the MGPS .......................................................... 5
3.1.1 Medical Air .......................................................................................... 5
3.1.2 Medical Oxygen .................................................................................. 5
3.1.3 Medical Vacuum ................................................................................. 5
3.1.4 Medical Nitrous Oxide ......................................................................... 5
3.1.5 Medical Carbon Dioxide ...................................................................... 6
3.2
Pipeline isolation valves ...................................................................... 6
3.2.1 Area Valve Service Units (AVSUs) ..................................................... 6
3.2.2 Lockable line valve assemblies (LVAs) ............................................... 8
3.2.3 Access to AVSUs, LVAs, MGPS manifolds and MGPS plant-rooms .. 8
3.2.4 MGPS key-holders .............................................................................. 8
3.2.5 Management of MGPS Cylinder Manifolds ......................................... 9
3.3.
Responsibilities ................................................................................... 9
Table 1- Medical gas cylinder manifold responsibilities .............................. 10
3.3.1 Manifold log-books ............................................................................ 10
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3.4.
MGPS monitoring and alarms ....................................................... 12
3.4.1
Actions in the event of a medical gas alarm .................................. 13
4. The MGPS permit-to-work system ......................................................... 14
4.1
Permit to Work Book .................................................................... 15
4.1.1
High hazard work ......................................................................... 15
4.1.1.1
Preparation for high hazard work ................................................. 15
4.1.1.2
Completion of high hazard work .................................................. 16
4.1.2
Low hazard work .......................................................................... 17
4.1.2.1
Preparation for low hazard work .................................................. 18
4.1.2.2 Completion of low hazard work..................................................... 18
5. Interruption to services provided by the MGPS ..................................... 18
5.1
Planned interruption ..................................................................... 18
5.1.1
Shut-down of services .................................................................. 19
5.1.2
Return to operation of MGPS services ......................................... 19
5.2
Electricity supply failure ............................................................... 19
5.2.1
Generator operation on mains failure........................................... 19
5.2.2
Complete electricity supply failure ............................................... 19
5.2.3.
Restoration of electricity supply ................................................... 20
6.
Emergency procedures ........................................................................ 20
6.1.
Emergency supply manifolds ....................................................... 20
6.1.1
Oxygen system ............................................................................ 21
6.1.2
Medical and surgical compressed air ........................................... 22
6.1.3
Nitrous oxide ................................................................................ 22
6.1.4
Medical Vacuum .......................................................................... 26
6.2
Failure of mains electricity supply ................................................ 26
Table 2: MGPS component performance during electrical failure scenarios ................ 27
Training .................................................................................................................. 28
Table 3 - Training schedule for persons working with medical gas systems ................ 28
A serious leak of medical gases .......................................................................... 29
Total or partial failure of a medical gas supply .................................................. 29
Contamination of a medical gas supply .............................................................. 30
Failure of an AGSS............................................................................................... 31
Over- or under-pressurisation of one or more gas systems ............................. 31
Emergency isolation of a gas supply .................................................................. 32
Fire ......................................................................................................................... 32
Pathology Gases .................................................................................................. 32
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Cylinder management .......................................................................................... 33
Use of oxygen at high concentrations ................................................................ 34
Standards .............................................................................................................. 34
Explanation of terms & Definitions ...................................................................... 34
References and Supporting Documents ............................................................ 35
Roles and responsibilities .................................................................................... 35
1. Chief executive ..................................................................................... 35
2. Authorising Engineer (AE-MGPS) ......................................................... 36
3. Authorised Person and Senior Authorised Person (AP-MGPS / sAP-MGPS) . 36
4. Competent Person (CP-MGPS) ............................................................ 37
5. Quality Controller (QC-MGPS) .............................................................. 37
6. Designated Medical/Nursing Officer ...................................................... 37
7. Designated Porter (DP-MGPS) ............................................................. 38
8. Medical Gases Committee (MGC) ........................................................ 39
9. MGPS Operational Policy and Procedures Review ................................. 39
Appendices............................................................................................................ 40
Appendix 1 ............................................................................................................ 40
Appendix 2 ............................................................................................................ 41
Appendix 3 ............................................................................................................ 45
Appendix 4 ............................................................................................................ 46
Appendix 5 ............................................................................................................ 47
Policy Implementation Plan .................................... Error! Bookmark not defined.
Monitoring and Review............................................ Error! Bookmark not defined.
Endorsement ............................................................ Error! Bookmark not defined.
Screening Equality Analysis Outcomes ................. Error! Bookmark not defined.
Who should read this document?
This policy applies throughout Salford Royal NHS Foundation Trust to all fixed
medical gas pipeline systems, associated plant equipment and the provision
of medical gases in cylinders. It is intended for use by all staff, PFI entities and
contractors involved with the use, operation and maintenance of Medical Gas
Pipeline Services (MGPS) and medical gases in cylinders.
For the purpose of this operational policy and their safe and appropriate use,
handling and storage, medical gases are defined as:
“A gas, in any form, intended for administration to a patient; either by
inhalation (including ventilation), application, inflation of any bodily cavity or by
any other means (including cardiopulmonary bypass and extracorporeal
ventilation equipment)”
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Key Messages
This policy addresses the provision of a Medical Gas Pipeline System
(MGPS) and Medical Gas Cylinder Service at Salford Royal NHS Foundation
Trust.
The MGPS provides a safe, convenient and cost-effective supply of medical
gases to points where these gases can be used by clinical and nursing staff
for patient care.
Salford Royal NHS Foundation Trust management recognises its commitment
to maintaining the MGPS to required standards and the training of all
personnel associated with its use, operation and maintenance.
Background & Scope
For the purpose of this operational policy and their safe and appropriate use,
handling and storage, medical gases are defined as:
“A gas, in any form, intended for administration to a patient; either by
inhalation (including ventilation), application, inflation of any bodily cavity or by
any other means (including cardiopulmonary bypass and extracorporeal
ventilation equipment)”
What is new in this version?




Change to new format
Additional plant
Removal of old plant & areas i.e. E to H block has been removed
New and updated APs & CPs
Policy/ Guideline/ Protocol
1. Exclusions
Compressed gas and vacuum supplies to general engineering workshops and
pathology department equipment are separate from the general MGPS, and
are not included in this policy, although the general principles in this document
should be followed for these departments.
Equipment connected to the terminal units is not covered by this policy, other
than where its mode of use may affect MGPS system operation or safety.
2. The MGPS structure
The Trust has a wide range of equipment and plant on site in respect of size
and age. These are located in several locations around the site shown in
Appendix 2.
All medical gas plant, manifold and service areas are kept locked and access
is restricted to Estates staff, authorised medical gas contractors and DPIssue 2
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MGPS. Keys for plant rooms are available from Estates in normal working
hours and must be signed in and out.
Outside normal hours access can be gained in an emergency via Security, or
non-emergency via the on-call engineer.
All keys for Area Valve Service Units (AVSU), Line Valves (LV) etc., can be
obtained from Estates in normal working hours, and via the on-call engineer
outside of normal working hours. Should a permit be required to carry out any
work, other than an emergency isolation, the on-call engineer will contact an
AP-MGPS.
3. Gases Provided through the MGPS
3.1.1 Medical Air
The Medical Air Systems (MAS) provide both medical air (MA4) and surgical
air (MA7) to the site.
If a compressor producing the air fails, a manifold comes on-line automatically
to support the plant. Plant and manifold rooms are located as shown on
Appendix 2.
3.1.2 Medical Oxygen
The Trust currently has two vacuum-insulated evaporator (VIE) plant
supplying all piped oxygen to the SRFT site. Medical liquid oxygen (MLO) is
delivered to the VIE by our medical gas supplier, who also maintain this
equipment. The supplier monitors levels of stored liquid oxygen via a remote
telemetry system and schedule deliveries according to usage trends and
requirements. The two feed independent sides of the site but can be used to
feed the whole site in an emergency.
In case of oxygen supply failure from the VIE, there is an emergency supply
manifold (ESM) located on Level 4 of the Turnberg Building which will
automatically come on-line. This ESM feeds only the Turnberg Building.
Emergency oxygen supply for other parts of the Trust will be met by use of
compressed gas in cylinders. This will be carried out by Portering Services
under the direction of the Duty Site Manager, AE-MGPS, AP-MGPS or DNOMGPS. The Areas served by the existing VIE are shown in Appendix 3.
3.1.3 Medical Vacuum
The Trust has several medical vacuum plants around the site. See Appendix 2
for their locations.
3.1.4 Medical Nitrous Oxide
The Trust has three Nitrous Oxide manifolds separately feeding Turnberg
Building , Radiology 2 and Maternity Theatres, respectively. See Appendix 2
for their locations
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3.1.5 Medical Carbon Dioxide
The Trust has one carbon Dioxide manifold feeding Turnberg Building Level 3
Theatre 2 also theatres H, J & K. See Appendix 2 for its location.
3.2
Pipeline isolation valves
3.2.1 Area Valve Service Units (AVSUs)
Area Valve Service Units (AVSUs) are locked boxes containing isolating
valves in enclosures with breakable glass fronts. AVSUs are provided at the
entrance to wards and departments. These valves provide facilities for both
routine and emergency isolation of gas supplies.
In general these valve boxes contain an emergency inlet port, which is gasspecific. This may be used to supply gas to a ward when the main supply fails
or is isolated in order to facilitate essential engineering work.
Some AVSUs do not have the facility to connect emergency supplies, and
these are in the old ward areas which are due for demolition.
In an emergency all AVSUs can be isolated by a responsible and trained
member of staff by one of two means:
1) rotating the black round valve (Maternity Block)
2) breaking the cover glass and closing the valve in the direction shown
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Figure 1: Typical layout for 2-gas A V SUs
Figure 2: Typical layout for 3-gas AVSUs
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3.2.2 Lockable line valve assemblies (LVAs)
Lockable pipeline valves are located at various points along pipes supplying medical
gases and allow engineers to isolate the section of pipe downstream from the valve.
These are called Lockable Line Valve Assemblies (LVAs).
LVAs located in ducts, risers, ceiling spaces etc., shall be locked in the normal
operating position.
LVAs located in a locked plant-room will normally be left unlocked in the normal
operating position.
Estates hold keys for all LVAs and all plant-rooms in which they are located.
Figure 3 - Typical LVA in plant-room
3.2.3 Access to AVSUs, LVAs, MGPS manifolds and MGPS plant-rooms
Under normal circumstances only the AP-MGPS, using the appropriate key from the
medical gases key cabinet, should access AVSUs and any other LVAs under the
control of a permit-to-work which has been signed by appropriate personnel in line
with the relevant procedures.
Medical gas plant rooms are usually locked using a suited key system that most
Estates staff and DP-MGPS would have day-to-day access. No work on the system
should be carried out without a permit to work. This excludes changing of bottles on
manifolds, routine maintenance or insurance work that does not require isolation of
the system which would prevent the required gas being received by the patient.
All work that requires isolation of any part of the system, or the provision of an
alternative gas supply for the patient requires a permit-to-work.
In the event of an emergency, access to the valve boxes and AVSUs may be gained
by smashing the breakable glass fronts.
Please note the following:
A DNO-MGPS, or other member of the nursing staff under the direction of a
DNO-MGPS, will perform emergency isolation after steps have been taken to
ensure that no patient is endangered by interruption of the medical gas
supply. No permit is required for this action.
3.2.4 MGPS key-holders
MGPS related locks are operable only by use of a specific set of suited keys, access
to which is strictly controlled and monitored. General master-keys will not work these
locks.
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For access to controlled areas MGPS Key-holders must be contacted. Out of hours
they can be contacted via switchboard.
A list of MGPS Key-holders can be found in Appendix 4
3.2.5 Management of MGPS Cylinder Manifolds
There are a number of medical gas cylinder manifolds around the hospital site, as
detailed in section 6.1 of this policy.
Only qualified personnel may have access to manifold rooms. However, in the case
of the Turnberg Building’s oxygen Emergency Supply Manifold (ESM) it is not
possible to completely restrict access due to the placement of the manifold. This
manifold and the associated hazards are clearly signed at both access points and
around the manifold itself.
Porters must not operate manifolds or replenish manifold cylinders unless
specifically trained to do so and their name is recorded on the DP-MGPS register.
3.3.
Responsibilities
Overall day-to-day responsibility for the safe operation and management of all
medical gas cylinder manifolds resides with the AE-MGPS and SAP-MGPS, this
includes repairs and maintenance to the manifold system, pipelines, cylinder
restraints and the buildings they reside in.
However, the duty of managing cylinder stocks and bank changes within these
manifolds lie with both Estates & Facilities and Portering Services, as outlined in the
table below:
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Table 1- Medical gas cylinder manifold responsibilities
Responsibilities:
Gas
Type
Manifold
Location
Cylinder
Stocks &
Rotation
Cylinder
Expiry
Dates
Cylinder
Bank
Changes
General
Housekeeping
(clean & tidy)
CO2
Entrance 4
DP-MGPS
DP-MGPS
DP-MGPS
DP-MGPS
N2O
Entrance 4
DP-MGPS
DP-MGPS
DP-MGPS
DP-MGPS
N2O
Maternity
DP-MGPS
DP-MGPS
DP-MGPS
DP-MGPS
N2O
Radiology 2 *
DP-MGPS
DP-MGPS
DP-MGPS
DP-MGPS
MA
Theatre Barn
AP-MGPS
AP-MGPS
AP-MGPS
AP-MGPS
MA
Neurosciences
AP-MGPS
AP-MGPS
AP-MGPS
AP-MGPS
MA
Entrance 3
AP-MGPS
AP-MGPS
AP-MGPS
AP-MGPS
MA
Maternity
Basement
AP-MGPS
AP-MGPS
AP-MGPS
AP-MGPS
MA
Ladywell
AP-MGPS
AP-MGPS
AP-MGPS
AP-MGPS
O2
Level 4
Turnberg
AP-MGPS
AP-MGPS
AP-MGPS
AP-MGPS
Responsibility for completing log-book entries lies with the individual operator at the
time of the activity taking place.
3.3.1 Manifold log-books
Each manifold on site has its own log-book adjacent to the manifold panel. This is as
required by HTM 02-01.
These log-books are a legal record of actions taken regarding the day-to-day
operation of the manifolds, therefore it is essential that all actions are recorded at the
point they are completed by the person performing the action.
All entries in manifold log-books must be made in permanent ink, such as ball-point
pen.
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Figure 4 - Example of a manifold log-book
All cylinder changes must be recorded by completing the required information under
each column heading:







Date and time
Batch numbers of all cylinders being connected
Expiry dates of all cylinders being connected
Position to which cylinders are being connected eg. left/right bank or
emergency reserve manifold (ERM)
Panel status eg. OK, alarm, pressure reading
Print name in full
Signature
Figure 5 - Example of a completed entry in a manifold log-book
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Other actions should be recorded ‘freehand’ (see above example of an engineering
check in the above photograph). These actions include:




Cylinder expiry date checks
Fault-finding checks
Engineering checks
Engineering work
3.4. MGPS monitoring and alarms
The MGPS is fitted with sensors at various locations in order to monitor the status of
the systems.
Each and every piece of plant equipment and manifold are monitored to some
degree, with newer installations showing more information than older ones.
Essentially, local system panels on manifolds and plant show more detailed
information relevant to the MGPS engineers, and more general information on
system status is relayed to the centralised status and alarm panels located in
switchboard.
Switchboard will notify the Portering Services Manager when cylinder changes are
indicated, and the SAP-MGPS (or his/her deputy in their absence) of any system
fault indications. An example of a central alarm panel in switchboard is shown in
Figure 6.
Figure 6 - Example of a 5-gas panel in switchboard
There should always be a green ‘normal’ light. If there is no green ‘normal’ light, then
there is a fault of some kind, possibly just with the alarm panel. Estates should be
informed so that they can investigate this fault.
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Wards and departments also have local ‘repeater’ alarm panels showing the status
of all medical gas pipelines providing services into their areas. Ward staff must be
aware of the functions and purpose of these panels,
and how to interpret and respond to alarm signals and status changes. An example
of a local alarm panel is shown in Figure 7.
Alarms must be tested each week by a CP-MGPS or AP-MGPS. Operation of the
test button will confirm operation of all audible/visual indicators. Nursing/medical staff
should be advised of this test.
Figure 7 - A typical local alarm panel found in wards and departments
3.4.1 Actions in the event of a medical gas alarm
On detection of a local alarm indication, for example in a ward area the senior duty
nurse, or other nominated person, should contact the switchboard to confirm that a
fault has been signalled and that Estates need to be informed. The DNO-MGPS for
the ward or department must also be informed.
It is the responsibility of the Authorised Person (MGPS) to ensure that a procedure
for each alarm indication is displayed next to the respective central alarm panel.
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In the event of an alarm condition on the central alarm panel, it is the responsibility of
the duty telephonist to inform the appropriate staff as shown in below.
Alarm Indication
Normal
Plant Faults
Plant Emergency
Reserve Low
Change cylinders
Change cylinders
immediately
Refill liquid (Main
VIE)
Refill liquid
immediately
(Main VIE)
Pressure fault
Power On
System Fault
Abbreviations:
Action ( Telephonist to inform )
No Action to be taken
NWH: Inform Estates
NWH: Inform Estates
Anytime: porters
Anytime: porters
Anytime: porters
NWH: Inform Estates
ONWH: Inform boilerman\engineer on call
ONWH: Inform boilerman\engineer on call
ONWH: Inform boilerman\engineer on call
No Action to be taken
NWH: Inform Estates
ONWH: Inform boilerman\engineer on call
(If this alarm shows it may indicate a fault. BOC should already be aware
via remote telemetry and should have called to advise us. If not Estates
need to inform BOC.)
NWH: Inform Estates
ONWH: Inform boilerman\engineer on call
No Action to be taken
NWH: Inform Estates
ONWH: Inform boilerman\engineer on call
NWH = Normal Working hours
ONWH = Outside Normal Working Hours
Disabling of the alarm system, other than when due authorisation has been
obtained from an AP-MGPS is strictly forbidden, as this may compromise
patient and system safety.
In the event of an alarm, upon it having been reported to switchboard and
Estates, it is acceptable that the audible alarm may be temporarily silenced.
This is achieved by pressing the ‘mute’ button. After a period of time the mute
function will cancel and the alarm will sound again.
The mute function must not be used repeatedly without further reporting the
situation, unless an AP-MGPS has been in contact and has given permission
to do so.
4. The MGPS permit-to-work system
The aim of the MGPS permit-to-work system is to safeguard:
 the health and safety of engineers working on the system
 the integrity of the medical gas system
 the safety of the patients
It is the policy of this Trust that, with the knowledge and permission of the AP-MGPS,
a permit must be raised before any work commences. The issuing of a permit-towork and the way in which the work is carried out must follow the directions of Health
Technical Memorandum 02-01 unless otherwise defined in this policy.
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The following actions do not require a permit-to-work to be issued:
Changing of manifold cylinders
VIE refilling
QC testing of medical/surgical air
Emergency isolation using AVSUs.
4.1
Permit to Work Book
HTM 02-01 clearly states that only one permit book for each of the two hazards
(High and Low) will be in use at any one time on the site. These books are kept in
the office of the SAP-MGPS in Estates & Facilities. It should be noted that the term
“Medium Hazard” is no longer in use and has been removed from the permit-to-work
system policy and procedures.
All completed permit books must be kept for the entire life of the system, and these
will also be kept at the above location.
Now the PFI hospital has become ‘live’, the above will apply to their MGPS staff. The
Trust’s AP-MGPS and the PFI’s AP-MGPS must work closely together to ensure that
any works carried out in respect of Medical Gases do not put patients at risk.
The PFI’s AP-MGPS must use the same permit books as the Trust and follow
this Operational Policy along with their own SOPs
4.1.1
High hazard work
Any work on the MGPS, such as cutting or brazing, that will introduce hazards of
cross-connection and pollution will be classified as high hazard.
Cross-connection, performance, identity and quality tests shall be required before
the MGPS is taken back into use.
High hazard work might require, at the least, a planned interruption to a single ward
or department or, at worst, a major shut-down of a system to a whole Trust site or
individual building, depending on the severity of the problem and which gas supplies
are affected.
4.1.1.1
Preparation for high hazard work
In such events, an AP-MGPS must ensure that key personnel for each ward or
department are informed; if necessary, he/she should hold a site meeting. If
appropriate, DNO-MGPS should be instructed that attempts should be made to
reduce gas consumption during the work.
The QC-MGPS should be included in any discussions that may lead to an
interruption of the MGPS.
Two weeks before the planned interruption, the Authorised Person (MGPS) shall
liaise in person with the DNO-MGPS responsible for the ward(s) or department(s)
concerned.
At this time the AP-MGPS will complete Part 1 of the permit-to-work form.
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The DNO-MGPS responsible for the ward(s) or department(s) involved will be made
aware that their signatures will be required on the day the work is due to commence
and before any work actually begins.
The requirement for portable cylinders or vacuum units will be determined by
discussion between the ward/department staff, DNO-MGPS and AP-MGPS. This will
later be confirmed along with details of the interruption by means of a memorandum
from the AP-MGPS responsible for the scheduled work. The memorandum will be
addressed to the DNO-MGPS responsible for the affected wards/departments, and
copied to those wards. The DNO-MGPS, or suitable deputy, must be available at the
time the work is due to commence.
Further memoranda requesting the services of the QC-MGPS and detailing the
requirements for portable cylinders shall be sent to QC North-West, the Pharmacy
Department and the Portering Services Manager, respectively.
It is the responsibility of the AP-MGPS to arrange with the Portering Services
Manager and Pharmacy Departments, or an appropriate hire firm if necessary, for
portable cylinders and regulators to be made available. Stocks of regulators are held
by Medical Physics.
Any additional portable vacuum units to be supplied are the responsibilities of the
wards/departments concerned.
The AP-MGPS will provide all details of the work to be carried out in Part 1 of the
permit-to-work form, including any other permits (for example for “hot works” or for
entry into confined spaces).
Work shall only commence when the senior duty nurse(s)/medical officers for the
ward(s) or department(s) is/are satisfied that no patients will be put at risk by the
shut-down of the MGPS and has/have signed Part 1 of the permit to-work form.
The AP-MGPS will then isolate the appropriate part(s) of the MGPS by way of the
AVSU(s) or LVA(s) only after:


Confirming isolation details by consultation with the CP-MGPS; and
Examining the sketch on the fourth sheet of the permit and any additional
drawings (if available).
Once the system(s) has/have been isolated and depressurised, the CP-MGPS will
sign:



Part 2 and
together with the AP-MGPS, sign the fourth sheet of the permit-to-work form,
and
commence work
4.1.1.2
Completion of high hazard work
Upon completion of the work the CP-MGPS will sign Part 3 of the permit to certify
that work has been completed. He/she will then contact the AP-MGPS to examine
and test the installation.
Depending upon the extent of high hazard work the AP-MGPS, with the assistance
of the CP-MGPS, will determine and carry out the necessary examination and testing
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of the system(s). This will be in accordance with Chapter 15 “Validation and
verification” in Part A of Health Technical Memorandum 02-01.
Upon satisfactory completion of these tests, the AP-MGPS will initial the relevant
spaces and sign Part 3 of the permit.
The QC-MGPS, with the assistance of the AP-MGPS, will carry out identity and
quality tests on the system(s). This will be in accordance with Chapter 15 “Validation
and verification” in Part A of Health Technical Memorandum 02-01.
Upon satisfactory quality control test results being obtained, both the QC-MGPS and
AP-MGPS will sign Part 4 of the permit.
Unsatisfactory results may lead to cancellation of the permit. In this case the
AP-MGPS will discuss with the SAP-MGPS, QC-MGPS and CP-MGPS any
remedial action required. If system interruptions are to be extended beyond
the original expected time-scale, the AP-MGPS must liaise with senior
ward/department staff and the DNO-MGPS responsible for the area(s) affected
and notify the Pharmacy Department and Portering Services Manager of
continued requirements for alternative medical gas supplies.
At this point an adverse incident report may be appropriate if there is a
perceived risk to the safety of patients or staff.
The AP-MGPS will issue the pink copy of the permit to the QC-MGPS.
The DNO-MGPS will accept the system(s) back into service by signing Part 5 of the
permit and will undertake to notify his/her colleagues that the system is fit and ready
for use.
The AP-MGPS will then issue the yellow to the CP-MGPS for their records. It is
important that the yellow copy should be signed off by all parties before being
handed over to the CP-MGPS.
The AP-MGPS must retain the white copy, and the fourth sheet in the permitto-work book.
4.1.2
Low hazard work
Any work on the MGPS which will not introduce any hazard of cross-connection or
contamination into the system will be classified as low hazard work.
A performance test will be required before the MGPS is taken back into use.
If there is any doubt as to the hazard level classification of a particular permit-towork, advice should be sought from the Senior AP-MGPS (SAP-MGPS).
Low hazard work on terminal units is normally the result of a leak on an individual
terminal unit due to a faulty valve or seal, but may also include work on plant which
does not interrupt gas supplies.
This type of work is often carried out at short notice due to the need for minimum
disruption to patient care.
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4.1.2.1
Preparation for low hazard work
The AP-MGPS may have to arrange a portable cylinder or vacuum unit so that the
terminal unit can be taken out of service.
The AP-MGPS will fill out the relevant section of Part 1 and the fourth sheet of the
permit-to-work form. He/she will liaise with and fully brief the DNO-MGPS, or in their
absence the senior duty nurse/medical officer of the ward/department. The DNOMGPS, or their deputy, will then sign Part 1 if required.
The AP-MGPS will provide all details of the work to be carried out in Part 1 of the
permit-to-work form. These should relate directly to the sketch on the fourth sheet of
the permit. When satisfied with the extent of the work the CP-MGPS will:



sign Part 2, and
sign the fourth sheet of the permit-to-work form together with the AP-MGPS,
and
commence work
4.1.2.2
Completion of low hazard work
The CP-MGPS will sign Part 3 of the permit to certify that the work has been
completed. He/she will then contact the AP-MGPS for the installation to be examined
and tested.
With the assistance of the AP-MGPS the CP-MGPS will, if necessary, perform flow,
pressure drop and mechanical function and gas-specificity tests on the installation.
Other equipment function tests, for example on plant, will be performed to the
satisfaction of the AP-MGPS.
The AP-MGPS and CP-MGPS will initial the relevant spaces and sign Part 3 of the
permit.
If he/she is satisfied with the test results the AP-MGPS will sign Part 4 of the permit,
or indicate that further work is necessary. If further work is necessary and requires
more extensive or prolonged system interruption, he/she must liaise with the DNOMGPS regarding the nature of further works and expected length of interruption.
Once the AP-MGPS has signed Part 4 the DNO-MGPS, or their deputy, of the ward
or department will accept the MGPS back into service by signing Part 5 of the permit.
He/she will then undertake to notify his/her colleagues that the system is fit and
ready for use or requires further work.
5. Interruption to services provided by the MGPS
5.1 Planned interruption
A planned interruption will be needed for repair, extension or modification to the
existing MGPS. An Authorised Person (MGPS) shall supervise any planned
interruption in strict accordance with the permit-to-work system as per the current
Health Technical Memorandum.
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The Quality Controller (MGPS) shall be involved in any planned interruption from the
initial planning stage.
The Authorised Person (MGPS) shall assess the hazard level of the work to be
carried out in accordance with the definitions that are given in section 7 of this policy
for high and low hazard work. (Medium hazard is no longer used as a classification.)
5.1.1 Shut-down of services
Pre-planned work on the MGPS requiring isolation of a plant, or part of the system,
will be covered by the MGPS permit-to-work system.
All necessary additional gas supplies should be in place before the work starts. This
may involve the provision of portable emergency supply systems and/or additional
provision of cylinder regulators from Medical Physics.
No isolation should take place without full liaison between the AP-MGPS, DNOMGPS and all other disciplines.
Attempts should be made to reduce gas consumption during the work.
5.1.2 Return to operation of MGPS services
Once work is completed, the procedure for handing over the MGPS back to clinical
use is described in section 7 of this policy (permit-to-work).
5.2
Electricity supply failure
5.2.1 Generator operation on mains failure
During changeover from electrical mains to emergency generator supplies, there is
always a possibility that spurious MGPS alarms, or changes in plant indications, may
be generated.
These alarms must be investigated immediately, as they could represent genuine,
rather than false, conditions.
The status of equipment such as compressors should also be checked to ensure
they are operating as selected: on, on stand-by, on duty mode or off.
5.2.2 Complete electricity supply failure
It must be remembered that the failure of generator and mains supplies
simultaneously will result in failure of the central medical vacuum systems.
It is important that clinical and nursing personnel are aware of this risk to the vacuum
system and any patients using it.
All relevant staff must undertake training in the use of emergency vacuum
equipment.
In areas where vacuum supply is considered critical, locally-generated vacuum will
have to be provided. However, with a failed electricity supply, this will not be possible
using the normal electrically-driven portable suction units.
For critical care use, ejector-driven suction units can be used. These are usually
powered from the main oxygen or air supply via a terminal unit, or from a separate
compressed gas cylinder (oxygen or medical air).
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An alternative would be a battery-driven suction unit, but it is important that with this
type of unit the battery is maintained in a fully-charged condition.
A portable vacuum unit is usually located on the department or ward crash trolley. To
locate extra units please call Medical Physics.
Failure of both mains and electricity supplies will also mean that the medical air
compressors will not function.
Emergency supplies of medical air will be provided from the automatic cylinder
manifold unit, but clinical staff must attempt to conserve air wherever possible so that
essential supplies to patient ventilators are maintained.
5.2.3. Restoration of electricity supply
Estates staff must ensure that all plant equipment and alarms have reset to full
operating conditions on restoration of power.
Wards and departments must be made aware that MGPS services have been
restored. This should be done via the AP-MGPS or DNO-MGPS.
6.
Emergency procedures
6.1.
Emergency supply manifolds
Emergency supply manifolds (ESMs) are attached to some medical gas systems.
They are located as shown in Appendix 2.
IMPORTANT! - Cylinder manifolds have severely limited capacity in comparison to
the normal demand supplied from a VIE. Additional portering or estates staff will be
required in the event of main MGPS plant or VIE failure, in order to change the
cylinders on the manifolds and to bring the replacement cylinders to the manifolds.
Measures to reduce gas consumption must also be considered.
See section 10 (cylinder management) for the provision of emergency cylinder
supplies.
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6.1.1 Oxygen system
In the event of failure of the primary VIE oxygen supply, the secondary VIE supply
will automatically provide the entire site with gas.
Figure 8: Primary VIE medical liquid oxygen storage vessel
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Figure 9: Secondary VIE liquid oxygen storage vessel (left of picture)
There is an ESM that feeds the Turnberg building only.
The ESM activates automatically in case of VIE supply failure and will change banks
automatically. This system requires cylinders to be replaced as each bank empties.
The system has a second VIE at entrance 4 and can be linked to the existing VIE by
the AP or CP opening / closing values to feed the whole site in the event of one VIE
failing.
6.1.2 Medical and surgical compressed air
The automatic manifold supporting the medical air plant will come on line
automatically and will change banks automatically.
Cylinder replacement will be the responsibility of Estates. Care should be taken to
prevent transfer of oil/grease from the compressor plant to the manifold cylinder
connections.
6.1.3 Nitrous oxide
The nitrous oxide manifold systems are fitted an ESM which will activate
automatically in the event of failure of, or loss of gas from, the main manifold.
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However, when in use it will not change from left to right cylinder banks
automatically, and this must be monitored and done manually in order to ensure
continuation of supply.
Estates and portering staff should be fully trained in the operation of this ESM.
Detailed instructions identifying which valves to turn and in which order are posted
adjacent to each ESM.
Due to the limited capacity of the ESM, it is essential that the pressure in the
cylinders be monitored continuously while it is in use.
Manual changeover from an almost empty bank to the full bank will be required.
A full cylinder must then replace the empty one.
Figure 10: A duplex Medical Air Plant
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Figure 11: A cylinder manifold providing backup for a Medical Air plant
Figure 12: The left bank of the Nitrous Oxide manifold supplying Theatres
Levels 1 & 3
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Figure 13: A Nitrous Oxide manifold ESM
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6.1.4 Medical Vacuum
The medical vacuum system has no emergency reserve manifold system. Failure of
the plant for any reason will result in total failure of the vacuum service.
Figure 14: A typical medical vacuum plant
6.2
Failure of mains electricity supply
In the event of an electricity failure, medical gas supplies should be maintained by
the emergency generator system (the “essential” supply).
The surgical compressed-air plant, vacuum plant, oxygen system, all manifolds and
medical gas alarm systems are connected to the “essential” electricity supply and will
continue to provide and monitor gas supplies as normal.
In the event of the failure of both mains and generator supplies all compressor,
vacuum and AGSS plant equipment will cease to operate. Only the liquid oxygen VIE
and gases provided through cylinder manifolds will continue to function.
If the electricity supply to an alarm panel only is interrupted, the panel will display a
“system failure” red warning light and emit an audible alarm; gas supplies will not be
affected.
See table 3 below for system performance under electricity failure situations, and
details of alternative supplies.
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Table 2: MGPS component performance during electrical failure scenarios
Medical
Gas
Service:
Operable during electricity
failure?
Mains Generator
failure: (“essential”) failure:
O2
Alternative
sources:
Additional actions:
Auto-engage
ESM (supplies
Turnberg Building
only)
Estates to arrange
emergency delivery of
cylinders for manifold.
M.A.4
Auto-engage
ESM
Estates/porters to
stand-by for immediate
and frequent cylinder
changes.
M.A.7
Auto-engage
ESM
Estates/porters to
stand-by for immediate
and frequent cylinder
changes.
N2O
Auto-engage
ESM
CO2
Auto-engage
ESM
Vacuum
Local portable
suction units
(battery or
ejector-driven)
Contact Medical
Physics to locate
portable suction units
as necessary.
A.G.S.S.
No
Assess risk of
continued use without
AGSS. Evacuate nonessential personnel
from area. Rotate
essential personnel to
avoid over-exposure of
individuals, if possible.
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Estates/porters to
stand-by for immediate
and frequent cylinder
changes.
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Training
It is essential for the safety of patients that no person should operate or work on any
part of an MGPS, including medical gases in cylinders, unless adequately trained or
supervised.
Training records of all persons trained for specific medical gas related roles, as
detailed in Section 3 of this policy, will be kept as part of the “MGPS Responsible
Persons Register” and be updated by the MGC. See table 1 for details of training
schedules for these roles, and responsibility for ensuring that training is up to date
and reported to the MGC.
Training for DP-MGPS will be delivered externally by designated trainers who have
undergone specific training to do so. It is not necessary for DP-MGPS to complete
the medical gas safety e-learning program, as the DP-MGPS course covers all
required elements. The manager of Portering Services must keep records of all DPMGPS training and send copies to the sAP-MGPS.
General medical gas safety training for all nursing staff and all other staff, as relevant
to their duties, will be administered by e-learning and recorded as a part of
mandatory training.
It forms the basis of all medical gas training and as such must be undertaken prior
to, and in addition to, any training requirements for the use of specific gas related
medical equipment.
It is the duty of ward and departmental managers to ensure that all staff working with
the MGPS, medical gas cylinders, or medical gas equipment are appropriately
trained and that such training is recorded. In addition, all staff bear the responsibility
to only carry out duties for which they are competent and have received the correct
training.
Table 3 - Training schedule for persons working with medical gas systems
Role
Retraining
Re-assessment
AE-MGPS
AP-MGPS
CP-MGPS
DNO-MGPS
DP-MGPS
TRAINER
DP-MGPS
Every 3 years
Every 3 years
Every 3 years
Every 3 years
Every 3 years
Every 3 years
Every 3 years
Every 3 years
Every 3 years
Every 3 years
Every year
Every year
General &
Nursing Staff
Every year
Every year
Prompted/monitored/
reported to MGC by
ERMG
AE-MGPS
AP-MGPS
sAP-MGPS
AP-MGPS
Portering manager, but
overseen by sAP-MGPS
Line managers (via
snowdrop)
AE-MGPS and AP-MGPS may request training records of any contractor’s staff.
All staff of external organisations working for the Trust indirectly, such as PFI staff
and contractors, who work on the MGPS, must be adequately trained in accordance
with the current HTM. Any records of training supplied must be kept in the training
file in Estates by the sAP-MGPS.
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In the event of medical gas supply interruptions due to mains power failure:




The Authorised Person (MGPS) must be informed of the situation via the nursing
staff/telephonist;
Portering and estates will arrange for staff to monitor manifold gas consumption,
replacing empty cylinders as necessary until the electricity supply is restored;
The Authorised Person (MGPS) will arrange emergency cylinder/regulator
supplies as necessary;
The Authorised Person (MGPS) will monitor the situation and confirm resetting of
compressor and vacuum plant and system alarms following restoration of supply.
A serious leak of medical gases
In these events:


The duty porter, DNO-MGPS and AP-MGPS will be contacted by the
telephonist/duty nurse
Details of the leak should be confirmed:










the floor level
department
room number
the gas or gases involved
whether patient ventilators are in use
Outside normal working hours, the on-call engineer will notify the AP-MGPS
It is the responsibility of the duty nurse or DNO-MGPS to carry out isolation of
medical gases to the area after ascertaining that no patients will be put at risk in
any area(s) affected by the isolation
The duty nurse will issue appropriate instructions to make the situation safe, such
as to open windows in the affected area and close doors, in accordance with the
Trust fire policy
The duty porter will remain on stand-by to provide extra gas cylinders as required
The AP-MGPS will arrange for repairs to the system(s) affected to be carried out
under the permit-to-work system
Total or partial failure of a medical gas supply
In these events:



The person discovering the failure will inform the telephonist and duty nurse
immediately
The telephonist will inform the duty senior manager, the duty porter, the
appropriate DNO-MGPS and the duty AP-MGPS of the leak
Details of the failure should be confirmed:


floor level
department
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










room number(s)
the gas or gases involved
whether patient ventilators are in use
As a precautionary measure, the telephonist will also notify critical care areas that
a failure has occurred on part of the system so that they are prepared in the
event of the fault extending to their departments
It is the responsibility of the duty nurse to check which patients may have been
put at risk by the failure and, if necessary, to arrange immediate emergency
medical action
Depending on the reason for the failure and its possible duration, the AP-MGPS
will decide the most appropriate method of long-term emergency gas provision.
This may involve establishing locally regulated cylinder supplies at
ward/department entrances
Nursing and medical staff should attempt to reduce gas consumption to a
minimum during the emergency
Portering staff will be required to monitor/replenish cylinders at any emergency
stations and at plant room ESMs
Pharmacy will arrange emergency cylinder deliveries as necessary
The AP-MGPS will liaise with the CO-MGPS to complete emergency repairs
needed to reinstate the gas supply, using the permit-to-work system
When the supply is fully restored, the AP-MGPS will complete a critical incident
form and produce a full report, which will be given to the Chief Executive and
Chief Pharmacist within 24 hours of the incident
In situations where it is envisaged that there will be long-term loss of oxygen or
medical air service, the duty senior manager will liaise with clinical colleagues,
including the senior nurse manager, the medical director and the Authorised Person
(MGPS) on the need for transfer of critically ill patients to other areas within the
Trust, as department closure may be warranted in extreme events.
If this can not be achieved the senior manager will be responsible for locating
alternative clinical care.
Contamination of a medical gas supply
It is not unusual for a smell to be noticed when using “plastic” equipment hoses to
deliver gas to a patient. This smell usually disappears rapidly after first use of the
hose, and will generally be familiar to operatives.
However, if either operatives or patients complain of any unusual or strong smells or
tastes from equipment, the situation must be treated seriously and immediate action
taken to ascertain the cause.
Where it is obvious that the smell is coming from the pipeline rather than a piece of
connected equipment, the gas supply must not be used.
In such an event, the fault should be treated as a complete gas failure to that area
and the actions described above taken immediately.
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It is very important that, if such an incident occurs, the AP-MGPS advises all
departments of the problem immediately, especially critical care areas.
Contamination of the medical vacuum system will usually be detected during routine
maintenance inspection and evidenced by the presence of liquid in the on-line
bacteria-filter drain flask. The infection control nurse should be informed immediately
and should advise on any additional precautions to effect the safe filter change.
Portable suction units may be used in areas where there is a possibility of the
vacuum system being contaminated.
(The need for portable suction units should be discussed with the infection control
officer.)
It is the responsibility of the CP-MGPS to change the filter in accordance with local
procedure, or as described in Health Technical Memorandum 02-01, and any
additional advice from the infection control officer.
If the contamination is due to system misuse, the AP-MGPS must complete an
incident report form. The form is to be sent to the risk manager so that the
appropriate nurse manager can be informed and remedial action taken.
Decontamination of pipework (if necessary) should be carried out in accordance with
the procedure described in Health Technical Memorandum 02-01 before filters are
changed.
Failure of an AGSS
Failure of an AGSS results in spillage of gaseous/vaporised anaesthetic agents into
the area in which the system is used.
In theatres, it is likely that staff exposure to the spilled gases will exceed the COSHH
recommendations for exposure when working in the area for extended periods, even
though ventilation rates are high.
A local alarm “system fail” warning and failure of the air receiver flow indicator will
alert staff to the system failure.
Both should be inspected by operating department staff on a regular basis.
The AP-MGPS and the theatre manager will be informed of the failure by the theatre
technician/ODP/anaesthetist, and all attempts should be made to reduce staff
exposure if operations must continue with a failed system.
When repairs have been completed, and the permit-to-work has been signed by the
theatre/nurse manager (or their nominated deputy), that person signing-off the work
should ensure theatre staff are aware that the system is back in use.
Over- or under-pressurisation of one or more gas systems
Local alarms are designed to indicate when system pressures are outside of the
normal operating range.
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Excessively high or low pressures may cause medical equipment to malfunction.
The duty nurse should report all instances of local alarm operation to the telephonist.
Emergency isolation of a gas supply
This procedure and the value of posting instructions have been referred to earlier in
this section. Mention should be made of the associated nursing/medical staff training
in emergency isolation actions.
No isolation should take place without full liaison between the Authorised Person
(MGPS) and all other disciplines.
Responsibilities for signing a permit-to-work lie with the Designated/Medical Nursing
Officers in each department.
Officers should ensure that colleagues are advised of the interruption to the gas
supply and its estimated duration.
Officers should also ensure via the AP carrying out the work that all affected terminal
units are appropriately labelled.
Fire
Procedures in accordance with the Trust fire policy should be followed in the event of
a fire involving, or likely to involve, the MGPS.
During a fire, the senior brigade officer will assume full control of the area(s)
affected.
Under no circumstances should medical gas supplies be isolated until the DNOMGPS has confirmed that all patients likely to be affected have been evacuated
and/or have alternative gas provision.
Pathology Gases
It should be noted that the Trust has several piped Pathology gas services on site.
The outlets of these are all located in the laboratories on the 2nd floor of the Turnberg
building and fed from a dedicated Pathology gas manifold. There is a further system
in the 2nd floor plant room of Turnberg building.
The gases do not come under the remit of the MGPS or the AP-MGPS. They are the
responsibility of the Pathology department. Estates take out an annual service
contract, on behalf and funded by the Pathology department, for the manifolds that
the Pathology gases are connected to. On request from Pathology, Estates will
arrange for a specialist contractor to attend to any faults on the Pathology systems.
Service sheets from the specialist are kept in the Estates department, along with all
the medical gas service reports.
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Cylinder management
The Trust has one central store for medical gases this is based at entrance 4, all
departments and wards are supplied from this store there are two sections to the
store which allows for the segregation of full and empty cylinders.
There is also a small stock of cylinders in the Maternity building, this is stocked from
the main store and the portering services return all empty cylinders to our main store
on at entrance 4 for the company to collect.
The company that supply our cylinders (BOC) deliver to this store twice a week
Tuesday/ Friday, the delivery is called (milk round) this being that all cylinders are
replaced on a one to one bases.
Each ward is supplied with either an F or ZX sized oxygen cylinder, these are to be
use in an emergency if the piped oxygen was to fail. They are kept in carriers on the
ward for staff to transport them around the ward if needed; these carriers are used
by the porters while they transport them to our main cylinder store when they need
changing.
The trust policy is in line with the recent EAF/2010/008 alert, all wards/ departments
are not allowed to have any other size cylinders
Only Medical Gas APs can request either G/J size cylinders which would be
used when the piped medical gas services were being isolated for
maintenance\upgrade work.
The portering services are responsible for changing any cylinders on the manifolds
that are situated across the site in the locations listed in appendix 2 of the Trust
Policy the only persons carrying out these works will be specifically trained medical
gas porters, the Estates department are responsible for changing any medical air
cylinders on manifolds as per appendix 2 of the Trust Policy only medical gas AP\CP
will carry out this work.
The company also deliver directly to the medical gas manifold room at entrance 4
this deliver point is for delivery of CO2 and N2O cylinders for connection to the main
theatre manifolds. After the cylinders have been changed they are taken to the main
store to be collected, these do not form part of the milk round deliveries mentioned
above.
The final delivery point for cylinders is the Medical Air manifold which is located at
the rear of the Barn Theatres when requested by the AP medical gases a collection
of empty cylinders and delivery of full J size cylinders will be made to this area, this
is to reduce the Manual Handling risks
All porters attend the Trust manual handling courses.
We have porters that have attended the medical gas training course, a record of
these porters shall be kept by the portering manager and a copy forwarded to the
Trusts Senior AP for medical gases so that they can be entered into the training
section of the operating manual. All staff will receive annual training in accordance
with the current HTM.
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It will be the responsibility of the portering manager to make sure training and
records are kept upto date. Only trained porters will be allowed to work on the
Trusts medical gas system. Copy of training certificates to be forwarded to the
Trusts senior AP for inclusion in the operational policy (Live).
All porters are told to advise staff that any equipment for repair should be reported at
ward level to Medical Physic.
 Flow meters
 Regulators
 Suction equipment
All porters that change the cylinders on the manifold systems are instructed that it is
their responsibility to change the cylinders and if there is a leak on the cylinder check
that the O rings are not worn on the connection and to replace O rings as required, if
there is still a leak they should contact any of the Trust APs immediately during
normal working hour or the duty engineer out of normal hours so that the faults can
be rectified.
Use of oxygen at high concentrations
Where oxygen is in use in large quantities and/or in higher than normal
concentrations, for example in oxygen tents and incubators, warning notices
indicating “high concentration oxygen in use – danger of fire” should be posted at the
treatment site.
The Trust fire officer should be consulted on the use of toys in oxygen tents, and a
notice worded “only toys, cosmetics etc approved by the fire officer are allowed in
this area” must be posted at the entrance to the treatment area.
It is the responsibility of all staff in such areas to be vigilant in all aspects of the
treatment, and appropriate safety training must be given in the use of oxygen under
these conditions.
[The use of small adhesive warning triangles, posted adjacent to oxygen terminals, is
becoming commonplace. If such notices are to be used, mention should be made of
this in the policy. Additionally, appropriate staff training should be given in the
identification and significance of these warnings.]
Standards
HTM02-01
Explanation of terms & Definitions
ADNS
AE-MGPS
AGSS
AP-MGPS
AVSU
Issue 2
October 2014
Assistant Director of Nursing Services
Authorising Engineer - Medical Gas Pipeline Services
Anesthetic Gas Scavenging systems
Authorised Persons - Medical Gas Pipeline Services
Area valve service units
Operational policy for the management of medical gas
pipeline systems and medical gas cylinders
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CO2
COSHH
CP-MGPS
CSB
DNO-MGPS
DP-MGPS
ERMG
ESM
HTM
LV
LVA
MAS
MGC
MGPS
MLO
N2O
NWH
ODP
ONWH
PFI
QC – MGPS
SAP
SOP
SRFT
VIE
Carbon Dioxide
Control of Substances Hazardous to Health
Competant Persons - Medical Gas Pipeline Services
Clinical Science Buidling
Designated Nursing Officers - Medical Gas Pipeline Services
Designated Person - Medical Gas Pipeline Services
***
Emergency supply manifold
Health Technical Memorandum
Line valves
Line valve assemblies
Medical Air Systems
Medical Gases Committee
Medical Gas Pipeline Services
Medical liquid oxygen
Nitrogen Oxide
Normal working hours
Operating Departmental Practicioner
Outside normal working hours
Private Finance Initiative
Quality Controller - Medical Gas Pipeline Services
Senior Authorised Person (s)
Standard operating procedures
Salford Royal Foundation Trust
Vacuum-insulated evaporator
References and Supporting Documents


COSHH
Health & Safety at work
Roles and responsibilities
For names and job titles of persons currently performing MGPS specific roles, please
see document “MGPS Responsible Persons Register” held on the Medical Gases
section of the Trust intranet (Clinical Services/Diagnostics & Clinical Support
Services/Medicines Management/Medical Gases).
1. Chief executive
Ultimate management responsibility for the MGPS rests with the SRFT Chief
Executive.
The Chief Executive herein delegates written appointment of Authorised Persons
(AP-MGPS) to the Authorising Engineer (AE-MGPS).
The Chief Executive herein delegates the day-to-day management responsibility for
the MGPS to the Senior Authorised Person(s) (Senior AP-MGPS).
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2. Authorising Engineer (AE-MGPS)
The duties and responsibilities of the AE-MGPS are:






3.
To recommend to the Facilities Manager those persons who, through individual
assessment, are suitable to be AP-MGPS and Senior AP-MGPS
To appoint in writing (by recommendation from the director of Pharmacy) a
quality control pharmacist with MGPS responsibilities
To ensure that all AP-MGPS have satisfactorily completed appropriate training
To ensure that all AP-MGPS are re-assessed every three years and have
attended a refresher or other training before such re-assessment
To review the management systems of the MGPS, including the permit-to-work
system
To monitor the implementation of the operational policy and procedures through
a program of audits
Authorised Person and Senior Authorised Person (AP-MGPS / sAPMGPS)
A minimum of three AP-MGPS are required for SRFT, and will be based on-site.
The AP-MGPS assume effective responsibility for the day-to-day management and
maintenance of the MGPS and associated systems.
The duties and responsibilities of the AP-MGPS are:










To ensure that the MGPS is operated safely and efficiently in accordance with
all statutory requirements and guidelines
To manage the permit-to-work system, including the issue of permits to
Competent Persons (CP-MGPS) for all servicing, repair, alteration and
extension work carried out on the existing MGPS
To supervise the work carried out by CP-MGPS and monitor the standard of
that work
To keep an up to date register of all CP-MGPS (including any contractors used)
To ensure that the SRFT MGPS maintenance specification and schedule of
equipment (including all plant, manifold, pipes, valves, terminal units and alarm
systems) are kept up to date
To liaise closely with Designated Nursing Officers (DNO-MGPS), the Quality
Controller (QC-MGPS) and others who need to be informed of any interruption
or testing of the MGPS
To liaise with and organise the attendance of the QC-MGPS as required
To provide technical advice to those responsible for the purchase of any
medical equipment which will be connected to the MGPS, in order to avoid
insufficient capacity and inadequate flow rates
To provide advice, in accordance with the Trust’s policy on provision of
services, on provision and/or replacement of MGPS central plant and
associated systems
To organise such training of Facilities staff and transfer of MGPS information as
is needed for the efficient and safe operation of the MGPS
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
4.
To attend Trust Medical Gases Committee meetings
Competent Person (CP-MGPS)
All CP-MGPS are experienced and qualified craft persons (eg. fitter, plumber,
welder, etc.). SRFT uses a mixture of Trust-employed and contractor CP-MGPS.
Trust-employed CP-MGPS must be suitably qualified, trained and assessed for the
role of CP-MGPS prior to appointment into the role. A list of all appointed CP-MGPS
must be kept, along with records of their qualifications, training and assessment.
Minimum training requirements are set out in current applicable Health Technical
Memorandum.
Contractors used as CP-MGPS must be registered to BS EN ISO 9001 / BS EN ISO
13458, with clearly defined registration criteria, and must meet the same minimum
standards of training, qualification and experience as Trust-employed CP-MGPS.
The duties and responsibilities of CP-MGPS are:

To carry out work on the MGPS in accordance with the SRFT maintenance
specification, and perform engineering tests appropriate to all work carried out,
and inform the AP-MGPS of all test results

To carry out repair, alteration or extension work as directed by an AP-MGPS in
accordance with the permit-to-work system and current applicable HTM 02-01

To carry out all work in accordance with SRFT health and safety policy
5.
Quality Controller (QC-MGPS)
The Trust has no provision for internal pharmaceutical quality control testing and this
function is provided under contract by QC North West.
The duties and responsibilities of the QC-MGPS are:

To assume responsibility for the quality control of the medical gases at the
terminal units (that is, the wall or pendant mounted medical gas outlets)

To liaise with the AP-MGPS in carrying out specific quality and identity tests on
the MGPS in accordance with the permit-to-work system, and in line with British
and/or European Pharmacopoeia standards (as applicable)

To organise MGPS training for pharmacy staff who may deputise for the QCMGPS
He or she should have received training on the verification and validation of MGPS
and be familiar with the requirements of this MGPS operational policy.
6.
Designated Medical/Nursing Officer
The role of Designated Medical Officer will not be used, as it is more appropriate to
the management structure of wards and clinical areas and services that senior nurse
management assume the duties of Designated Nursing Officers.
However, in a minority of circumstances this role may not actually be performed by
qualified nurses.
From hereon in, the term Designated Nursing Officer MGPS (DNO-MGPS) will be
used.
Matrons, ADNS and Site Coordinators will assume the duties and responsibilities of
DNO-MGPS, thus providing around-the-clock cover for this essential role.
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In operating theatres it may be practical for an Anaesthetic Department Practitioner
(ADP) to assume the role of DNO-MGPS.
Training will be provided for staff assuming DNO-MGPS roles, in accordance with
the training schedule as described in Section 5 of this policy. As part of the DNOMGPS training, those staff assuming DNO-MGPS duties and responsibilities must
familiarise themselves with local MGPS provision, layout and alarm panels, in
addition to this Operational Policy.
Upon satisfactory completion of the training schedule all DNO-MGPS will be signed
on to the site register by the SAP-MGPS.
It is the policy of SRFT that all MGPS work in wards and departments carried out
under the MGPS permit-to-work system will be controlled by the DNO-MGPS
responsible for each area.
Out of hours such work would only be carried out in an emergency, and in which
case the site-coordinator should be contacted.
The duties and responsibilities of the DNO-MGPS are primarily those of
communication and liaison:








7.
To liaise with medical and nursing staff who use the MGPS, and the AP-MGPS,
to ensure that the MGPS is appropriate to departmental needs
To be present upon request of the AP-MGPS to give permission for any
interruption to the MGPS, and to sign the appropriate parts of the permit-towork
To assist and coordinate emergency response, as appropriate with the APMGPS, in the event of a sudden MGPS failure or emergency shutdown of
MGPS systems or parts thereof
To carry out emergency MGPS isolation of wards or departments, as
appropriate and as set out in this Operational Policy, by use of the area valve
service units (AVSUs) and notify the AP-MGPS of the situation
To ensure, in co-operation with the AP-MGPS, that all medical and nursing staff
are aware of interruptions to the MGPS and any restrictions on use of terminal
units
To liaise with AP-MGPS and ward/clinic duty managers to oversee and sign-off
work permits for all high-hazard and multi-system/multi-area engineering work
involving the MGPS
To act as the focal point for communications related to the MGPS and advise of
any special requirements for their area(s) of responsibility, such as emergency
cylinders, compressors and vacuum pumps
To liaise with the other DNO-MGPS and delegate a DNO-MGPS to attend each
MGC meeting
Designated Porter (DP-MGPS)
A Designated Porter (DP-MGPS) is a porter with particular responsibilities for
medical gases. He or she will have undergone specialist HTM compliant training in
the identification and safe handling and storage of medical gas cylinders, including
relevant manual handling training and connection to and disconnection from medical
gas equipment and manifolds.
The duties and responsibilities of DP-MGPS are:
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pipeline systems and medical gas cylinders
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






To deliver full gas cylinders from the gas stores (as appropriate) to wards and
departments
To collect and return empty or surplus cylinders from wards and departments to
the appropriate gas stores
To transfer gas delivery notes to the Pharmacy Department
To attach to and remove from cylinders, medical equipment, gas regulators and
manifold tail-pipes (as appropriately trained to do so)
To identify and remove from service any faulty (e.g. leaking, stuck valves, etc.)
cylinders and immediately notify the Pharmacy Department of the details and
location of such cylinders. Isolation of faulty or incident cylinders is described
later in this policy
To rotate stock of cylinders as necessary to ensure cylinder contents are used
within their expiry dates, and to avoid overstocking
To maintain manifold-change log books, monitor manifold cylinder expiry dates,
and to change manifold cylinders in a timely manner prior to the expiry of
cylinder contents
The DP-MGPS must work safely at all times using the appropriate personal
protective and manual handling equipment, damage to which must be reported
immediately to the Head of Portering Services.
8.
Medical Gases Committee (MGC)
The Medical Gases Committee meets quarterly. Minutes and Agenda of meetings
are kept on the Pharmacy Medicines Management Server, managed and updated by
the secretary of the committee.
The Terms of Reference document is published on the Trust intranet.
9.
MGPS Operational Policy and Procedures Review
The MGPS Operational Policy and all related policies and procedures will be
reviewed every two years, or as becomes necessary with changes in best practice,
relevant legislation, site layout or new or altered MGPS equipment and plant.
.
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Appendices
Appendix 1
Medical Gas Training Records
Name
Role
Date
trained
Date
Appointed
Renewal
Period
William Lundy
Authorised Person
Oct-05
Dec-05
Every 3 years
Gary Butcher
Authorised Person
Jul-08
Jan-09
Every 3 years
Dave Emmens
Authorised Person
Sept-12
Rob Hornby
Authorised Person BBW
Sep-11
Every 3 years
Christopher Alderson
Authorised Person BBW
Nov-11
Every 3 years
Kevin Morris
Competent person
Oct-13
Every 3 years
Robert Chalmers
Competent person
Oct-13
Every 3 years
Keith Ashworth
Competent person
Jul-12
Every 3 years
Every 3 years
Competent person
contractor
Competent person
contractor
Medigas
Medical Pipeline Services
Every 3 years
Every 3 years
NB: Trust to request as required proof of competency of all contractors
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Appendix 2
Appendix 2
Medical Air Equipment
Location
Level 0 Plantroom
Turnberg
Provides both Medical and Surgical Air
Type of
System
Quad
Manifold
Manifold
Size
Location
2 x 12 Adjacent to
main Elec
switch room
2x4
Same room
Ladywell Plantroom
Duplex
Neurosciences
Plantroom
Entrance 3
Plantroom
Maternity Basement
Plantroom
Duplex
2x8
Same room
Triplex
2x5
Same room
Triplex
2x5
In Main
Plantroom
Issue 2
October 2014
ERM
Yes
Yes
Yes
Yes
Keys
Available
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Operational policy for the management of medical gas
pipeline systems and medical gas cylinders
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Area Fed by plant
Turnberg all
Levels
Ladywell All
levels
Ground Floor and
MR Scanner
Removed Aug 11
Maternity all
floors
Page 41 of 48
Vacuum Plant
Type of
System
Manifold
Size
Manifold
Location
ERM
VAC
N\A
N\A
N\A
VAC
N\A
N\A
N\A
VAC
N\A
N\A
N\A
VAC
N\A
N\A
N\A
VAC x 2
N\A
N\A
N\A
E Cellar (HCU)
VAC
N\A
N\A
N\A
G Block
Vac
N\A
N\A
N\A
Radiology 1
Vac
N\A
N\A
N\A
E Cellar (K Ward)
VAC
N\A
N\A
N\A
Location
Level 0 Plantroom
Turnberg
Ladywell Plantroom
Neurosciences
Plantroom
Phase 2 Building
Plantroom
Maternity Basement
Plantroom
Issue 2
October 2014
Keys
Available
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Estates or
Security
Operational policy for the management of medical gas
pipeline systems and medical gas cylinders
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Area Fed by plant
All Levels
turnberg
Ladywell All
levels
Ground Floor and
MR Scanner
All B wards
Maternity all
floors
Removed Aug 11
Removed Aug 11
CT Bodyscan
Radiology 1
Removed Aug 11
Page 42 of 48
Oxygen Plant
Location
O2 Emergency
Turnberg only
Type of
System
Manifold
Size
Manifold
2x5
Manifold
Location
Turnberg level
4
Keys
Available
Area Fed by plant
N\A
Estates or
Security
All levels
Turnburg
ERM
VIE 1
Liquid
O2
Boiler Hs Car
Park
Yes
Estates or
BOC
VIE 2
Liquid
O2
Entrance 4
Yes
Estates or
BOC
Ladywell Brook
Building and
Hope Building
Turnberg, Irving
and Humphery
Booth
Nitrous Oxide
Location
Entrance 4 Med
Gas Room
Radiology 1
Maternity
Type of
System
Bottle
Gas
Bottle
Gas
Bottle
Gas
Manifold
Size
Manifold
Location
1x1
Medical Gas
Room
Outside Gas
Room
2x2
Maternity
2 x 12
Issue 2
October 2014
ERM
Yes
Yes
Yes
Keys
Available
Estates or
Security
Estates or
Security
Estates or
Security
Operational policy for the management of medical gas
pipeline systems and medical gas cylinders
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Area Fed by plant
Theatres
CT Bodyscan
Radiology 1
Maternity
Page 43 of 48
Carbon Dioxide
Location
Type of
System
Manifold
Size
Manifold
Location
Entrance 4 Med
Gas Room
Bottle
gas
2x3
Medical Gas
Room
Issue 2
October 2014
ERM
No
Keys
Available
Area Fed by plant
Estates or
Security
Theatres 2, H,J &
K
Operational policy for the management of medical gas
pipeline systems and medical gas cylinders
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Appendix 3
Alarm Indication
Normal
Plant Faults
Plant Emergency
Reserve Low
Pressure fault
Action ( Telephonist to inform )
No Action to be taken
NWH Inform Estates ONWH Inform boilerman\engineer on
call
NWH Inform Estates ONWH Inform boilerman\engineer on
call
Anytime porters
NWH Inform Estates ONWH Inform boilerman\engineer on
call
Panel Indication all alarms Panels
Alarm Indication
Power On
System Fault
Action ( Telephonist to inform )
No Action to be taken
NWH Inform Estates ONWH Inform boilerman\engineer on
call
Abbreviations: NWH = Normal Working hours ONWH + Outside Normal Working Hours
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Appendix 4
Key Holders
Name \ Department
Availability
Contact Number
W Lundy
Normal working hours
64502
G Butcher
Normal working hours
60340
D Emmens
Normal working hours
61629
Boilerman
Outside normal hours
Via Switch
Security
All hours
Via Switch
On Call Engineer
Outside normal hours
Via Switch
Porters
All hours
Via Switch
BBW Site
Normal working hours
68330
BBW Site
Outside normal hours
Via Security
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Appendix 5
Copy of instructions in Estates On Call Bag for Engineer On Call
Medical Gas Instruction Sheet
The estates departments’ responsibility for medical gases is from the source of the gas to the outlet on the wall or pendent.
No temporary or permanent repairs will be carried out on any anaesthetic or medical equipment by estates staff. All repairs of this
nature must be referred to the anaesthetic department or medical physics.
Permit to Work on Piped Medical gas systems
A permit to work will be issued by the trusts Appointed Person for medical gases in accordance with HTM 02-01.
There are two levels of permits to be issued Low Hazard and High Hazard. The permit books are kept in the Estates Department
and should be returned when not in use. Keys for use on medical gas systems should be signed for from Estates and returned
each day so that they are available in an emergency overnight or at weekends
During normal working hours a permit can be obtained from one of the following APs (Authorised Persons)
Mr W Lundy Estates Officer Electrical
Tel: 206 4502
Mr G Butcher Engineering Project Officer Tel: 206 0340
Mr D Emmens Estates Officer Mechanical Tel: 206 1629
PFI Site
Mr R Hornby
Tel: 206 8330
Outside normal working hours the duty engineer will be contacted by the telephone switch. The duty engineer will make a
decision as to what work is required and if necessary contact one of the APs for advice or to attend site to issue permits etc.
The duty engineer will also have access to the Medical Gas Specialist contractor for any repairs.
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Issue 2
October 2014
Operational policy for the management of medical gas
pipeline systems and medical gas cylinders
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