Document Title: Medical Gas System Management

Document Type: Policy/Procedure Plan Guideline Clinical Practice Guideline Bylaw

Document Originating
21/10/2020
Date:
Document Effective Date: 3/6/2023
Revision Number: V.1
Originating Entity: Facility Management Department
Approved by: Facility Management Director, Chief Operation Officer
Document Ref: POLFM0005
Scope: Medical Gases Technicians at Abdali hospital
Next Revision Due Date: 6/2026

I. Purpose:
1.1 The purpose of this policy is to describe how can handle and store the medical gas cylinders.

II. Policy:
2.1 This policy applies to the supply, delivery, installation and maintenance of the medical gas
service from the point of supply, up to and including the terminal outlets.
2.2 This policy lays down the mandatory requirements for the activities associated within
medical gas pipeline systems for the supply of:
2.2.1 Medical Oxygen.
2.2.2 Nitrous Oxide.
2.2.3 Medical Compressed Air (4 Bar).
2.2.4 Surgical Compressed Air (7 Bar).
2.2.5 Medical Vacuum.
2.2.6 Anesthetic Gas Scavenging Systems.
2.3 This policy will cover handling and storage medical gas cylinders:
2.3.1 Carbon Dioxide Cylinders.
2.3.2 Compressed Air Cylinders.
2.3.3 Oxygen Cylinders.
2.3.4 Oxygen Crash Cart Cylinders.
2.3.5 Oxygen for Respirator/OR Cylinders.

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 2.3.6 Oxygen Cylinder for PFT.
2.3.7 Nitrogen Cylinders.

III. Definition:
3.1 Medical gas systems: include the pipes, fixtures and other apparatus for medical gas, and
vacuum systems. These systems also include anesthetic gas scavenging system along with
medical air, nitrous oxide, oxygen, nitrogen, carbon dioxide, and other gas mixtures.

IV. Responsibilities:
4.1 It’s the responsibility of medical gas technician to follow the procedure inside this policy.

V. Procedure:
5.1 Liquid Oxygen System:
5.1.1 System Description: Oxygen is supplied from a tank located to operating rooms,
birthing center, recovery rooms, treatment rooms, emergency room, ICU, CCU and
other patient care areas via a central gas system. Complete medical gas distribution
drawings are found are located in the Engineering Department.
5.1.2 Normal Operation: In normal operation, the bulk storage tank supplies oxygen to
the hospital through a main valve located at the tank.
5.1.3 Backup Operation: cylinders back up on an automatic transfer manifold located on
the tank.
5.1.4 Alarms: A low-pressure set point of 3.8 bar has been established. A high-pressure set
point of 4.8 bar has been established. Upon an alarm condition, a visual and audible
alarm occurs at the local alarm panel. The departments involved shall notify
engineering department who will proceed to ascertain and correct the problem.
5.1.5 Test/Inspection/Maintenance: shall be checked daily for operation during daily
equipment rounds. The system is also inspected and maintained on a periodic basis
through the hospital’s preventive maintenance program. Records of repair shall be
kept in Engineering Department.
5.1.6 System Alarms Testing: The system alarms shall be tested dynamically by decreasing
the system pressure below the set point and check the all alarms parameters.
5.1.7 Results of Tests/Inspections: The results of the inspections, testing, or corrective
actions shall be recorded on the checklist PM sheets. The sheets shall be
documented in the engineering department.

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 5.2 Nitrous Oxide System:
5.2.1 Normal Operation: In normal operation the nitrous oxide is delivered by a central
system from a manifold/cylinder bank located in the cylinder room at B1.
5.2.2 Alarms: which are audible, visual and linked to local control panel, will appear when
the system pressures drops/increases beyond the set point, and the departments
involved shall notify engineering department to take the necessary action.
5.2.3 Testing/Inspection/Maintenance: shall be inspected on daily basis. The system is
also inspected and maintained on a periodic basis through the hospital’s preventive
maintenance program. The checklists and repairs reports shall be recorded in the
Engineering Department.
5.2.4 Systems Alarms Testing: The nitrous oxide alarms shall be tested quarterly by
decreasing the system pressure below the set point and check the activation of
system alarms.
5.2.5 Testing Results: The results of inspections, tests, and corrective actions shall be
recorded on checklist sheets.
5.3 Carbon Dioxide System:
5.3.1 Normal Operation: In normal operation the carbon dioxide is delivered by a central
system from a manifold/cylinder bank located in the cylinder room at B1.
5.3.2 Alarms: which are audible, visual and linked to local control panel, will appear when
the system pressures drops/increases beyond the set point, and the departments
involved shall notify engineering department to take the necessary action.
5.3.3 Testing/Inspection/Maintenance: shall be inspected on daily basis. The system is
also inspected and maintained on a periodic basis through the hospital’s preventive
maintenance program. The checklists and repairs reports shall be recorded in the
Engineering Department.
5.3.4 Systems Alarms Testing: The nitrous oxide alarms shall be tested quarterly by
decreasing the system pressure below the set point and check the activation of
system alarms.
5.3.5 Testing Results: The results of inspections, tests, and corrective actions shall be
recorded on checklist sheets.
5.4 Medical Air System:
5.4.1 System Description: The medical air system is composed of quadruplex medical air
compressor systems.

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 5.4.2 Normal Operation: In normal operation the quadruplex system, located in the
Basement 1, operate in rotation.
5.4.3 Backup Operation: cylinders back up on an automatic transfer manifold at the tank.
5.4.4 Equipment Maintenance: Medical air compression equipment shall be checked on
daily basis. The equipment is also inspected and maintained on a periodic basis
through the hospital’s preventive maintenance program. Records of repairs and
performed preventive maintenance shall be documented by the Engineering
Department.
5.4.5 Alarms: A low-pressure set point of 3.7 bar has been established. A high-pressure set
point of 5 bar has been established. Upon an alarm condition, a visual and audible
alarm occurs at the local alarm panel. The departments involved shall notify
engineering department who will proceed to ascertain and correct the problem.
5.4.6 Results of Testing: The results of inspections, testing, and corrective actions shall be
filed on the PM checklist sheets located in the Engineering Department.
5.5 Surgical air compressor plant:
5.5.1 System Description: The surgical air system is composed of simplex medical air
compressor systems.
5.5.2 Normal Operation: In normal operation the simplex system, located in the Basement
1, operate in rotation to equalize the operation hours of the compressors.
5.5.3 Backup Operation: cylinders back up on an automatic transfer manifold at the tank.
5.5.4 Equipment Maintenance: Medical air compression equipment shall be checked on
daily basis. The equipment is also inspected and maintained on a periodic basis
through the hospital’s preventive maintenance program. Records of repairs and
performed preventive maintenance shall be documented by the Engineering
Department.
5.5.5 Alarms: A low-pressure set point of 6.5 bar has been established. A high-pressure set
point of 7.5 bar has been established. Upon an alarm condition, a visual and audible
alarm occurs at the local alarm panel. The departments involved shall notify
engineering department who will proceed to ascertain and correct the problem.
5.5.6 Results of Testing: The results of inspections, testing, and corrective actions shall be
filed on the PM checklist sheets located in the Engineering Department.
5.6 Medical Vacuum System:
5.6.1 System Description: The medical vacuum system is composed of centrifugal
compressors for podium, main lab and tower.

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 5.6.2 Normal Operation: Under normal conditions the vacuum pumps will be alternated
as duty to equalize the running working hours.
5.6.3 Alarms: A low alarm set point of (- 0.77 bar) has been established. The alarm
conditions exist and linked to local control panel. The Engineering Department shall
be notified of an alarm and shall proceed with the necessary action.
5.6.4 System Failure Procedures: In the event of a system-wide failure of all three vacuum
pumps, which will result in a vacuum outage of greater than 15 minutes, the
maintenance personnel will notify the PBX operator. The switchboard will in turn
notify Surgery, Maternity, ER, ICU, OR, CCU, and all nursing units. All units may
obtain portable suction equipment as needed.
5.6.5 Testing/Inspection/Maintenance: Vacuum pump equipment shall be checked daily
for operation during daily equipment rounds. The equipment is also inspected and
maintained on a periodic basis through the hospital’s preventive maintenance
program. Records of repair shall be kept in Engineering Department.
5.7 Compressed Gas Cylinders:
5.7.1 Medical gas cylinders should be stored in a purpose-built cylinder store to keep the
cylinders safe and proper stored.
5.7.2 Appropriate signage on the door to advise that gas cylinders are inside.
5.7.3 covered top store, preferably inside the building.
5.7.4 Avoid subjection to high temperature.
5.7.5 Keep the cylinders in dry, clean and well-ventilated store.
5.7.6 Good access for transportation.
5.7.7 The store shall be away from storage areas containing highly flammable liquids and
other combustible materials.
5.7.8 Empty cylinders shall be so identified and stored separately from full or partially full
cylinders. Small cylinders of oxygen or other nonflammable gas required during
patient transport may be used when safely affixed to the patient bed or stretcher.
5.7.9 Allow for strict rotation of full cylinders to enable the cylinders with the oldest filling
date to be used first.
5.7.10Have warning signs prohibiting smoking and naked lights within the vicinity of the
store.

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 5.7.11Use of Cylinders:
5.7.11.1 Cylinders must be changed before the contents gauge drops into the red
zone, i.e. before the flow of gas stops due to the cylinder being empty.
5.7.11.2 Do not leave flow meters open if not in use with a patient. The cylinder
valve should always be closed when treatment is finished.
5.7.11.3 It is important that no part of the cylinder valve or equipment is either
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.
5.8 Anesthetic Gas Scavenging System (AGSS):
5.8.1 Definition: AGSS system has been designed to remove exhaled anesthetic gas
mixtures from operating theatres, anesthetic rooms and recovery areas.
5.8.2 alarms: The alarm conditions exist and connected to local control panel, the
engineering department shall be notified of the alarms and shall take the necessary
action.
5.8.3 Testing/ Inspection/ Maintenance: the system shall be inspected and maintained on
a periodic basis through the hospital’s preventive maintenance program, the
performed preventive maintenance shall be recorded by engineering department.

VI. References:
6.1 External References: N/A
6.2 Quality References:
6.2.1 JCI (2020). Joint commission international accreditation standards for hospitals. 7th
edition. Joint Commission International
6.2.2 HCAC (2021). Healthcare Accreditation Hospital Manual.4th edition. Healthcare
Accreditation Council.
6.3 Cross Reference: N/A

VII. Performance Indicator:

7.1 Outcome Indicator: N/A
7.2 Process indicator: N/A

VIII. Appendix: N/A

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IX. Revision History and Tracking:
Date Révision Numbers Section Affected Details Approval Date
19/12/2020 V.0 All sections - 19/12/2020
3/6/2023 V.1 No section affected - 3/6/2023

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