MEDICAL GASES POLICY

Transcription

1 MEDICAL GASES POLICY To be read in conjunction with the Health & Safety Policy and associated Estates documents Document Type H&S Policy Unique Identifier HS-009 Document Purpose Health and safety of employees and non-employees Document Author Health & Safety Managers reporting to the Company Secretary Target Audience All staff Responsible Group H&S Committee Date Ratified November 2011 Expiry Date November 2014 The validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on or Medical Gases Policy Page 1 of 18

2 Version History Version Circulation Job Title of Person/Name of Group Brief Summary of Change Date Circulated to 1 09/11 H&S Committee members and Union Merge of PCT and MHPT policy H&S Reps 2 10/11 JNCC N/A 3 11/11 Quality & Safety Committee Ratified for use Accessibility Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number ( ). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting Instant telephone interpreting Document translation British Sign Language interpreting Training and Development Worcestershire Health and Care NHS Trust recognise the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. Medical Gases Policy Page 2 of 18

3 Contents Page 1 Introduction 4 2 Legal Position 4 3 Purpose / Statement 4 4 Responsibilities 4 5 Training 6 6 Storage of Cylinders 6 7 Use and Handling of Cylinders 7 8 Manifold Cylinder Control 7 9 Maintenance 8 10 Permit To Work 8 11 Emergency Procedures 8 12 Consultation, Development & Approval 9 13 Dissemination 9 14 Planning and Implementation 9 15 Monitoring and Review 9 16 Standards / Key Performance Indicators References 10 Appendices 1 Medical Gas Risk Management Tool 11 2 Emergency Procedures for Leaks 14 3 Equality Impact Assessment 16 Medical Gases Policy Page 3 of 18

4 1. INTRODUCTION This policy is to ensure the effective management of the medical gas pipeline systems (MGPS) within the Trust. This includes the provision of a safe, secure and reliable system, including cylinders and associated equipment. The policy is intended for use by all staff involved in the use, handling and maintenance of the MGPS and medical gas cylinders e.g.: medical oxygen, compressed air, liquid cylinders and medical vacuum. Additional procedures are available from the Estates department to outline the specific safe systems of work for each community hospital. 2. LEGAL POSITION Under the Health and Safety at Work etc Act 1974 (HSW Act), employers have a general duty to ensure, as far as is reasonably practicable, the health, safety and welfare at work of your employees. Employers also have a duty under the Management of Health and Safety at Work Regulations 1999, to assess the risks to the health and safety of your employees. Employees are required to take reasonable care of themselves and others who could be affected by what they do at work. An audit tool has been provided in the Appendix to assist with this process. 3. PURPOSE / STATEMENT The aim of the Policy is to ensure the health, safety and well-being of staff and patients by maintaining the safe use, handling, storage and maintenance of medical gas systems within Trust premises. The policy is intended to: Clearly establish what is expected of the staff who will be exposed to medical gases Help prevent incidents involving medical gases Ensure a safe and secure facility for storing medical gases 4. RESPONSIBILITIES 4.1 Chief Executive Ultimate responsibility for the MGPS rests with the Chief Executive. This responsibility is delegated to the Head of Estates. Day to day management responsibility for the MGPS will rest with the Estates Manager. 4.2 Authorising Engineer The Head of Estates is responsible for managing the Authorised Person(s) and ensuring they have completed appropriate training. They will review the management systems of the MGPS, including the permit to work system as required. 4.3 Authorised Person (MGPS) The Estates Manager is responsible for the maintenance and management of the MGPS. This authorised person must ensure that the systems are operating effectively and should be the only person who decides whether or not a system can be put into use. They require specific training and are re-assessed every three years. Medical Gases Policy Page 4 of 18

5 The Estates Manager is responsible for maintaining schematic diagrams of each locations MGPS, indicating pipe runs, isolating valves and terminal outlets, including a site plan showing sources of supply and distribution. These are available on the Estate Medical Gas Procedures specific to each location. They will be responsible for managing the permit to work system, including the issue of permits to Competent Persons for all servicing, repair, alteration and extension work on existing MGPS. They will supervise the work of the Competent Persons, as required. The Estates Manager will maintain a maintenance specification and an up to date schedule of equipment. They will liaise with the Matron and the Quality Controller to ensure members of staff are kept informed of any interruption or testing. They will also arrange any necessary training for designated staff e.g. Porters. 4.4 Competent Person (MGPS) Penlon are contracted to undertake maintenance work on the MGPS under the guidance and control of the Estates Manager. They require specific training and are re-assessed every three years. Any competent person must be registered as an ISO 9000 or operate an equivalent quality standard, and provide the Estates Manager with evidence of training. 4.5 Designated Medical/Nursing Officer (DMO/DNO) All MGPS work in hospitals carried out under the permit to work system will be controlled by the Matron. They will liaise with the Estates Manager to ensure this work is undertaken safely and efficiently. They will be responsible for ensuring that hospital members of staff are aware of any maintenance work and the expected duration of any interruption of supply. 4.6 Designated Porter (MGPS) These staff will be assigned specific responsibility for medical gases. Estates will arrange for them to attend any training in the identification and safe storage of gas cylinders. Staff will also attend relevant manual handling training via Central Training Services. Designated Porters will assist in the delivery of gas cylinders and the return of empty cylinders, attach and remove medical equipment regulators and manifold tail pipes from cylinders. They will identify and remove from service any faulty cylinders as well as perform a weekly check on cylinder stocks. 4.7 Quality Controller The Trust s Chief Pharmacist is the person responsible for monitoring the contents of the MGPS and the quality of the medical gases at the terminal outlet. 4.8 Premises Manager where MGPS is present: Be familiar and comply with the Medical Gases Policy. Ensure members of staff who handle/use medical gas are aware of the Policy. Alert the Authorised Person if there are any problems with the MGPS. Ensure a risk assessment is undertaken where MGPS are present and periodic auditing using Appendix 1. Medical Gases Policy Page 5 of 18

6 4.9 Employees involved in using/handling MGPS: To be familiar with the Medical Gases Policy. To undertake training as required to ensure safe use/handling. To report any concerns to their line manager. Be aware of the Estates procedures specific to their location which detail safe systems of work Health and Safety Committee Co-ordinating and monitoring implementation of this policy. Identifying, with managers, the resources required for staff training and other aspects of the implementation of this policy. Reviewing reports from the Sentinel Risk Management System regarding medical gas issues. 5. TRAINING Regular training is essential in order to ensure that all key personnel have a sound understanding of the principles, design and function of their MGPS. All authorised and competent persons will be suitably trained, experienced and familiar with their particular installations. Any clinical staff that use the MGPS must be instructed in the use of the system, in particular how to isolate the supply locally, and how to implement the emergency procedures. 6. STORAGE OF CYLINDERS Gas cylinders should be kept in a purpose built store that is in a safe location and complies with the following: Under cover, preferably inside and not subject to extremes of heat Be kept dry, clean and well ventilated at top and bottom Have good access for delivery vehicles and reasonably level floor to enable tail lift operation Allow for segregation of full and empty cylinders and permit separation of different gases within the store Allow for strict stock rotation of full cylinders so that oldest are used first Be totally separate from any non-medical cylinder storage areas Be sited away from storage areas containing highly flammable liquids or other combustible materials Medical Gases Policy Page 6 of 18

7 Be sited away from any sources of heat or ignition Have warning notices posted prohibiting smoking and naked lights within the vicinity of the store Allow for F, HX, G and J size cylinders to be stored vertically on concrete floored pens Allow for C, CD, D and E size cylinders to be stored horizontally on shelves Be designed to prevent unauthorised entry to protect against theft or tampering 7. USE AND HANDLING OF CYLINDERS The handling and connecting of cylinders to the MGPS is the Porters responsibility with back up provided by the Estates Department in the event of an emergency. The Porters must be suitably trained by the Estates Manager. Under no circumstances should untrained staff be allowed to change cylinders. When handling cylinders, the following precautions should be taken: Wear safety shoes and gloves Cylinders should only be moved with a trolley designed for appropriately sized cylinders Never roll cylinders along the ground as this may cause the valve to open accidentally. It will also damage to label and paintwork Cylinders should be handled with care, never knocked violently or allowed to fall over Never paint or obscure any markings or labels on cylinders Where possible, place cylinders near to an exit so that they can be moved quickly in an emergency Materials that do not normally burn in air, will burn more easily in oxygen, nitrogen oxide or medical gas mixtures containing these gases. Therefore, smoking or naked lights must not be permitted in the vicinity of a cylinder, a pipeline outlet or where cylinders are stored. When using cylinders ensure no part of the valve or equipment is lubricated or contaminated with oil or grease. This is due to the risk of spontaneous combustion that can occur with high-pressure gases in the presence of hydrocarbons. Special care is needed with the use of hand creams as these could provide sufficient contamination to the valve surface to cause an ignition when the valve is turned on. 8. MANIFOLD CYLINDER CONTROL All persons handling or responsible for MGPS and associated equipment should ensure they are familiar with the operating and safety procedures laid down in the manufacturer s user manual. Only persons who have received instruction or authorisation from the Estates Manager to handle or change cylinder manifolds will be allowed access into the manifold Medical Gases Policy Page 7 of 18

8 area. Procedures for storage and handling of single cylinders apply equally to cylinders used in manifold. When supplying cylinders to the manifold room, authorised staff should ensure that: Pipeline connections are leak tested when connected to cylinders Any separate emergency cylinders are full, available for use, checked and stock rotated The manifold room is not used as a general cylinder store Empty cylinders are removed immediately from the manifold room and returned to the main cylinder store MGPS alarm warning lights should be constantly visible to clinical staff and monitored at suitable locations. (Further instruction for authorised staff is detailed within the site specific procedures drafted by Estates). 9. MAINTENANCE Before any routine planned work is undertaken, the Estates Manager will provide the following information to the designated staff member responsible for the ward/department: The gas that is affected The time and date The down time The work content Where routine planned maintenance is carried out, the contractor will give 28 days notice in writing, prior to work commencing. If unplanned repairs are needed, then at least 7 days notice in writing will be given. Urgent repairs may not give any notice. In these circumstances, the Estates Manager will advise the clinical staff and Chief Pharmacist of the situation and anticipated downtime. No additional medical gas equipment/services should be connected to the MGPS without prior approval from the Estates Manager. This is required to ensure the system capacity is not overloaded and is compatible. 10. PERMIT TO WORK In line with HTM 02 a permit must be raised before any work can be undertaken on any part of a Medical Gas System, except when changing manifold cylinders, re-charging VIEs or liquid cylinder oxygen storage vessels or emergency isolation by a member of nursing staff. Responsibility for signing a Permit to Work lies with the Hospital Matron. The Matron will ensure that colleagues are informed of any interruption to the gas supply and the estimated duration of the work. 11. EMERGENCY PROCEDURES Medical Gases Policy Page 8 of 18

9 In the event of a fire, the safety of staff and patients is the first priority. Staff should follow their building fire evacuation arrangements. In the event of a medical gas incident it is the responsibility of the person in charge of the ward/department to ensure the system is turned off at the local isolating valve. This can be done by breaking the glass section of the valve box, then turning the valve handle to the closed position. During a fire, staff should remember that pressurised gas cylinders may explode if there is excessive heat, so people should evacuate to safe distance. When notifying the fire services, warn them of the presence of pipeline gas and/or gas cylinders. Only authorised members of staff should attempt to enter the manifold room (ie: medical gas house storage area), otherwise this could endanger lives. Never attempt to move cylinders unless it is safe to do so. Unless staff have been trained in the use of either fire extinguishers or hose reels, do not attempt to fight a fire in which cylinders are directly involved. All incidents should be reported immediately to the Estates Manager, or the on call Manager if out of hours. The Estates Manager will attend the site at the earliest opportunity to assess the situation. Only Penlon shall undertake repairs. These will be arranged with the Estates Manager and the person in charge of the ward/department will be informed accordingly. The Estates Manager will arrange for any damaged cylinders to be moved off site and returned to the supplier for examination. 12. CONSULTATION, DEVELOPMENT AND APPROVAL This policy is drafted and developed by the Health & Safety Managers and Estates staff in accordance with legislation and HSE best practice. Key stakeholders and specialist staff are involved in the consultation process e.g.: estates, clinical staff, accredited H&S reps and JNCC members. The Health and Safety Committee is responsible for approving the review of the policy. Final ratification of the policy rests with the Quality and Safety Committee. An equality impact assessment has been undertaken on the legal content and best practice guidance contained in the policy to ensure it is valid and applicable to all. 13. DISSEMINATION Policy documents are available via the Trust s website. The principles embedded within the policy will be included in Induction Training for staff and in the Health and Safety e-learning package. 14. PLANNING AND IMPLEMENTATION The Chief Executive will agree annual objectives related to health and safety and estates management with all Executive Directors who will ensure appropriate cascading of relevant objectives throughout the area of their responsibility. Executive Directors will ensure that health and safety planning forms an integral part of their business planning process, in order to ensure that needs are identified, prioritised, and that appropriate resources are allocated. 15. MONITORING AND REVIEW Estates staff will report any incidents involving medical gas systems to the Health and Safety Committee. The investigation and analysis of such incidents will be used as a tool to identify causation, reduce future likelihood and assess the effectiveness of policy controls. Medical Gases Policy Page 9 of 18

10 Policies will be subject to review in line with health and safety legislation or if there are changes to technology, processes or practice. The review of policies will also be based on the prioritisation of risk within the Trusts and as a consequence of any serious incidents. 16. STANDARDS/KEY PERFORMANCE INDICATORS Care Quality Commission requires the Trust to achieve a required level of compliance for health and safety control. This is Outcome 10: Safety and Suitability of Premises, also Outcome 11: Safety, Availability and Suitability of Equipment. 17. REFERENCES Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulations Healthcare Commission Standards for Better Health HTM 02 Part A and Part B. Reporting of Injuries, Diseases and Dangerous Occurrences Regs Control of Substances Hazardous to Health Regs Pressure Equipment Regs European Pharmacopoeia Society standards for medical gases Medical Gases Policy Page 10 of 18

11 MEDICAL GAS RISK MANAGEMENT TOOL Appendix 1 Location Name Date Date of Registration Name Job Title Signature PVH Regulations 2001 The registered person shall make suitable arrangements for the ordering, recording, handling, safe keeping, safe administration and disposal of medicines used in or for the purpose of the establishment Domain 1 - Safety Health care organisations keep patients, staff and visitors safe by having systems to ensure that medicines are handled safely and securely 15 (5) SfBH C20a & C4d 1. PHYSICAL SYSTEMS Comments Manifold Room a. Separate room to all else b. Access from outside on ground floor level ground c. Ventilated, well lit, and heated d. Only one bank of cylinders stored e. Adequate signs (Contents/ prohibition/ dangers etc) f. Log book detailing maintenance and checks Cylinder Store a. Separate room to manifolds b. Contains only medical gases c. Cylinders segregated by size, contents, full and empty and secured appropriately d. Ventilated and well lit e. Contains ONLY medical gas cylinders f. Access from outside on ground floor level ground g. Adequate signs Medical Compressor plant room a. Air intake for Compressors from clean area (eg Not from car park) Medical Gases Policy Page 11 of 18

12 b. Must NOT contain standby manifold c. Log book detailing maintenance and checks VIE (Liquid oxygen tank) a. Area fenced off and locked (and controls tamper proof) b. No debris, litter, vegetation, excessive icing in compound c. Maintains safety distances (Normally >5m to any hazard, bigger installations >7m) d. Adequate signage (inc parking restrictions) 2. PERSONNEL Comments Authorised Person (Medical Gas Pipeline System - MGPS) a. Recently trained (last 3 years) b. Qualified (i.e. min. qualification level ONC/HNC in engineering) c. Authorised (e.g. approved by engineer with experience) d. Appointed by Executive Manager to manage the MGPS Competent Persons a. Register held by AP (Authorised Person) b. Assessment carried out c. Copies of certification held by AP Training Schedule a. Details training events b. Medical gas staff training identified (Porters, Nurses, DM/NO) c. Results of training held and review details Medical Gas Committee (will be requirement of HTM 02) a. Members identified b. Meetings identified and minutes of past meetings held 3. DOCUMENTATION - GENERAL Comments Standards a. Has full copy of HTM 02 (Vol1 & 2) Supp. 1 if relevant b. PTW (Permit to work) MGPS book in place and used. Medical Gases Policy Page 12 of 18

13 c. COSHH assessments carried out for N 2 O d. Tests results for environmental monitoring of areas with N 2 O (e.g. theatres, recovery, maternity, etc) e. PPE available for staff handling cylinders Records (recommend kept for at least 2 years) a. Orders b. Delivery notes c. Purity certificates 4. POLICY & MAINTENANCE Comments Operational Policy a. Nominated personnel for stakeholders b. Defined roles and responsibilities c. Details normal and emergency procedures d. Describes system limitations and site layout e. Subject to issue control and review (dated) As Fitted Drawings a. Detailed as As fitted b. Dated with any revisions numbered c. Complete with valve chart matching installation (each valve numbered) Maintenance Specification a. Hospital Specific not generic b. Includes testing regime and results for Medical Air plant c. Includes testing regime and results for Anaesthetic Gas Scavenging (BS 6834) d. Maintenance contract or schedule in place e. Emergency call out procedure identified and posted Medical Gases Policy Page 13 of 18

14 Appendix 2 EMERGENCY PROCEDURE FOR A LEAK FROM A LIQUID NITROGEN SYSTEM 1. Evacuate all personnel from the area until ventilation can restore oxygen concentrations to safe levels. 2. Stop the leak if it is possible to do so without risk. 3. Ventilate the area if it is possible to do so without risk. 4. Notify porters and Estates personnel of any major spills or leaks. 5. Emergency personnel and anyone who enters the affected room must wear self contained breathing equipment. 6. Move the leaking container to outside if it is possible to do so without risk. 7. Allow the spilled nitrogen to evaporate, ensuring that no-one can enter the affected room. 8. Liquid Nitrogen Dewars are owned by the trust, but repairs can be carried out by BOC. EMERGENCY PROCEDURE FOR A LEAK FROM A LIQUID OXYGEN VESSEL 1. There is generally no danger from a leaking Oxygen vessel other than from the coldness of the leaking gas. 2. Ensure a No Smoking rule is strictly enforced. 3. The Liquid Oxygen Vessels are owned by BOC and any problems should be reported to them direct. Cryogenic systems are used at several localities for the storage of medical gases either oxygen or nitrogen. These include: Evesham Community Hospital Liquid Nitrogen (LN2). Princess of Wales Community Hospital - Liquid Nitrogen and Liquid Oxygen. Pershore Community Hospital Liquid Oxygen. John Anthony Centre Liquid nitrogen. Note: the Dewar is stored in an area that is open at the sides but covered and any leaks should not cause a problem. In the case of a leak at this property the unit should be left to empty out. Tenbury Community Hospital - Liquid Nitrogen and Liquid Oxygen. Malvern Community Hospital (New site) - Liquid Oxygen. Liquid gases will cause cold burns due to their extreme low temperatures and if in contact for any length of time fingers, etc could freeze completely. Liquid oxygen is obviously safe to breathe but it will greatly aid combustion. Smoking is therefore completely forbidden. Medical Gases Policy Page 14 of 18

15 Protective equipment and clothing must be used at all times when decanting any liquid gas. Any room that contains liquid nitrogen must be well ventilated and be fitted with a low oxygen alarm with a repeater outside the room to inform everyone that there is a problem and not to enter. Note these alarms are installed at waist height as nitrogen is heavier than air and it initially sinks to the ground, but as the concentration builds up so the danger level rises. The alarms must be tested on a regular basis and have their batteries changed every 12 months. Note: 1 Litre of nitrogen gas produces 0.7 cubic metres of gas a 700 fold increase. Do not allow objects cooled by the liquid to touch bare skin. Objects may stick to the skin and tear flesh away when you attempt to remove the object.cooled by liquid nitrogen. Nitrogen gas is colourless, odourless, tasteless and deadly! It reduces the concentration of oxygen and will cause suffocation. As it cannot be detected it may be inhaled as if it were air. As liquid nitrogen evaporates, the resulting nitrogen gas displaces the normal air. Breathing air that is less than 18% oxygen will cause dizziness, unconsciousness and even death. When liquid nitrogen is exposed to the air. The cloudy vapour that you see is condensed moisture and not nitrogen gas. The gas itself is invisible. FIRST AID If anyone working with liquid nitrogen becomes dizzy or loses consciousness, move them to a fully ventilated area at once - ENSURE THAT YOU OPERATE SAFELY and do not also succumb to the effects of the gas. Call a doctor. Apply artificial respiration immediately if the breathing has stopped or apply oxygen if they have difficulty breathing. If a person is exposed to liquid nitrogen or gas, the affected tissue should be restored to normal body temperature as soon as possible. Remove or loosen any clothing, belts, collars, etc that might restrict circulation to the affected area and bathe or immerse the area in water heated to 42 C. DO NOT heat the water above 45 C. Medical Gases Policy Page 15 of 18

16 Medical Gases Policy Appendix 3 Department Corporate Created Person Responsible Robert Hipwell Last Review Wednesday 14th December, 2011 Wednesday 14th December, 2011 Status Complete Next Review n/a Screening Data 1. What is the policy? (Name/description of the policy) Medical Gases Policy 2. What is the aim, objective or purpose of the policy? This document is intended to reflect the views of Worcestershire Health and Care NHS Trust (The Trust) and sets out the requirements and arrangements needed in order to meet any statutory requirements. The policy is supported by a number of other documents, which offer guidance about specific health and safety issues. The policy is drafted and developed by the H&S Managers and is available via the Trustâ s website. Key stakeholders and specialist staff are involved in the consultation process to ensure best practice e.g. infection control, H&S Representatives and estates staff. The policy applies to all individuals on NHS premises, reflects the Trustâ s equality and diversity arrangements. The principles embedded within it will be included in Induction Training for staff and in mandatory training updates. 3. Who implements the policy? All staff within the Worcestershire Health and Care NHS Trust 4. Who is intended to benefit from this policy and in what way? All individuals on NHS property 5. Is the policy applied uniformly throughout the Trust or only applicable to certain Business Units? Yes 6. Who are the stakeholders in relation to this policy (for example, certain groups of staff/students, visitors etc)? Medical Gases Policy Page 16 of 18

17 All individuals on NHS property 7. What data are available to facilitate the screening of this policy? N/A 8 Is there any evidence of higher or lower participation, uptake or exclusion, by any groups or individuals? 9. In the context of the preceding sections are there any relevant groups which you believe should be consulted? Please specify and give reasons: None 10 What data are required in the future to ensure effective monitoring? Potentially ethnicity/gender of people involved in incidents 11. Considering all information above please indicate areas where a differential impact occurs or has the potential to occur. 12. Any other comments on the policy None 13. Potential for differential impact? None Impact Assessment Data 1. Does the policy impact less favourably on a certain group or groups in comparison with others? 2. Is there any indication of a higher or lower participation/uptake rate by particular equality groups? 3. Do some groups have lower than average success rates in particular processes and/or access to services? 4. Do criteria or requirements in relation to the policy disadvantage certain groups, either explicitly or inadvertently? 5. Is access to services and benefits reduced or denied for some groups in comparison with other groups? 6. Do particular groups face increased difficulty or indignity as a result of the policy? 7. Are there higher complaints rates or lower satisfaction rates for particular equality groups in connection with the policy, in comparison with other groups? 8. Is there evidence that the policy fails to respond to the needs of a particular group, in comparison with other groups? 9. If you have identified adverse impact, could this amount to unlawful discrimination? Medical Gases Policy Page 17 of 18

18 10. If the policy intends to result in different outcomes for different groups by using positive action to redress disadvantages, is this lawful? Organisation Sign-off Data 1. Are you satisfied with the monitoring arrangements for this policy Yes 2. Have you read the policy and do you agree to accept and sign off? Yes Outstanding Actions No outstanding actions Medical Gases Policy Page 18 of 18