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Ensure empty O2 cylinders are stored separately and policies are clear

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August 18, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

Check all areas where your facility keeps oxygen cylinders to ensure empty and full cylinders are stored separately. And make your cylinder storage policy clear on where partially full cylinders are to be kept. Also, partial cylinders without pressure gauges should be stored with empty cylinders, says The Joint Commission (TJC).

While TJC has not changed any requirements, it has recently highlighted a Frequently Asked Question (FAQ) on storage management that clarifies storage of partial cylinders. TJC officials said the clarifications were made at the request of CMS.

More than a year ago, TJC reversed a long-standing position and revised its FAQ on oxygen cylinders to say that full and partially full cylinders could be stored together, as long as signs were clear about which cylinders they were. Cylinders also must be clearly marked per organizational policy as to whether they are full, partially full, or empty.

“I did notice the ‘Featured’ designation on the FAQ site, which makes me think one of two things,” says Steven MacArthur, a former hospital safety officer and now a senior consultant with The Greeley Company in Danvers, Massachusetts. “Either hospitals didn’t catch it when they shifted the official position back in late 2017, or the surveyors didn’t catch it and are citing hospitals for practice and conditions that are in compliance with what is noted in the FAQ.”

“At any rate,” says MacArthur, “there’s really nothing new.”

The earlier change in allowing opened but still usable cylinders to be stored in the full rack was significant at the time, notes Ernest E. Allen, ARM, CSP, CPHRM, CHFM, a former TJC Life Safety surveyor and now a patient safety executive with The Doctors Company in Columbus, Ohio. “Not all hospitals adopted it.”

“The change was helpful with costs, as placing a partially used cylinder in an empty rack could result in the cylinder being sent back to the supplier as empty when it was still almost full,” which results in additional cost to the hospital, says Allen.

But this year TJC is noting that some cylinders do not have pressure gauges.

The clarified FAQ states: “Partials without an integral pressure gauge and those equipped with gauges with depleted volume content (as determined by hospital policy) are to be stored with empty.”

Generally, a cylinder has a plastic tab on the top that must be removed to open it, and without a gauge to determine how much is in it, the cylinder still should be stored with the empty cylinders, advises Allen, who often conducts mock surveys for healthcare organizations.

“On my surveys of hospitals around the country, I would note that 95% use the grab-and-go type with a handle on top with a pressure gauge. That makes it easy to read the pressure to determine it is still usable per hospital policy.”

Some hospitals have three categories of storage, says Allen: full (unopened), partial (open but still with sufficient pressure to be used), and empty (below 500 or 750 psi, or whatever the hospital policy states).
“If there is sufficient space for three racks, that works well. But hospitals often lack storage space and only have room for ‘Full’ and ‘Empty’ racks,” he says.

The recently highlighted FAQ also notes that compliance with NFPA 99-2012, Health Care Facilities Code, requires no more than 300 cubic feet of oxygen storage in a smoke zone, notes Allen.

“Keep in mind if there is a separate storage room with a one-hour rating, you can store more than 300 cubic feet per smoke zone, as the cylinders in the fire-rated room do not count in the total. Also, some hospitals use UL one-hour rated cylinder storage cabinets to store full cylinders,” such as on a busy ICU unit, says Allen. “Technically the hospital could have 12 full oxygen cylinders in the smoke zone and another 12 full inside the UL rated cabinet and still could comply with the 300 cubic feet requirement.”

As for partially full cylinders, their storage location is up to the organization, notes Brad Keyes, CHSP, founder of Keyes Life Safety Compliance.

However, “a policy should be written that clearly identifies where partially full cylinders are stored,” says Keyes.

“It is important to note that Joint Commission does not have a standard that addresses partially full cylinders. Their standard EC.02.05.09, EP 12, specifically addresses the storage of full and empty cylinders, but is silent on where to store partially full cylinders. This is consistent with NFPA 99-2012,” he warns. 
According to Keyes, NFPA 99-2012, Section 11.6.5.2 says empty cylinders must be stored separate from full cylinders. Meanwhile, Section 11.6.5.3 says empty cylinders “shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.”

“That is all that NFPA says regarding the storage of full, partially full, and empty medical gas cylinders,” he says. “There is no specific instructions from NFPA (or CMS for that matter) on how and where partially full cylinders should be stored.”

The clarified TJC FAQ does state that “full and partially full cylinders not yet depleted—as determined by organization policy—are permitted to be stored together, unless the organization's policy requires further segregation.”

The TJC FAQ on oxygen cylinders can be found at tinyurl.com/y57jcua6.

 Correction:  A previous version of this article incorrectly said that Keyes Life Safety Compliance was recently acquired by Compliance One Group in Kalamazoo, Michigan. Compliance One acquired only the Keyes website, http://www.keyeslifesafety.com.
 




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