Somalia Regional State Gode general hospital

Dawladda Deeganka Somalida Cusbitalka Guud Ee Gode

Oxygen Cylinder Protocol

Introduction
Oxygen therapy is an essential component of medical care. It is used in emergency care, for
anesthesia, in surgery, and for managing acute and chronic respiratory conditions. However, the
COVID-19 pandemic led to an unprecedented surge in the demand for oxygen supply, given its
crucial role in treating COVID-19 patients. The respiratory complications due to COVID-19 can
lead to hypoxemia in patients, a condition when the oxygen level in the blood is abnormally low.
In such a condition, a patient requires oxygen therapy and access to quality-assured medical
oxygen. Reliable access to quality-assured medical oxygen can mean the difference between life
and death for patients.
Sometimes, even if oxygen is available, observations suggest that lack of oxygen access to
patients in health care settings can be due to insufficient oxygen systems medical gas pipeline;
medical grade oxygen generation plant; oxygen concentrators (OC); and low-quality and poorly
maintained oxygen delivery equipment like ventilators, concentrators, continuous positive
airway pressure (CPAP), and bi-level positive airway pressure (BiPAP). Such shortcomings
could be due to deficiencies in clinical and technical training and skills among clinical, technical,
and administrative healthcare workers. Thus, creating awareness among the health care
professionals and building their capacities to operate and maintain oxygen supply equipment
efficiently is of paramount importance. Therefore, an enabling environment is required to
streamline efforts to ensure that patients receive oxygen therapy, when needed. These efforts
include safeguarding the quality of oxygen supplied by manufacturer, assuring its appropriate
administration to the patient, and drastically improving the screening of hypoxemic patients.
Purpose of the Standard Operating Procedure (SOP)
This document, titled “Operation and Maintenance of Oxygen Cylinder”, provides guidance to
all staff on safe use and operation of the compressed oxygen gas cylinders in health care
facilities. The SOP includes the following components: types of cylinders, labelling a cylinder,
installing a cylinder, using a cylinder, when and how to change a cylinder, handling a cylinder
(initial safety checks, general and fire safety considerations), storing and transporting a cylinder,
troubleshooting and preventive maintenance of cylinder, calculating oxygen consumption from
cylinder, etc. The SOP intends to bridge knowledge and skill gap among health care facility staff
by providing in-depth information on the operation and management of an oxygen cylinder.
Scope
The specifications and guidelines in the “Operations and Maintenance of Oxygen Cylinder”
intend to support health facility administrators, clinical practitioners, procurement officers,
planning staff, biomedical engineers, infrastructure engineers, and policymakers in the states and
at the national level to select, procure, use, and maintain oxygen cylinder. This document may
also be of interest to health care workers, academics/researchers, development agencies, non-
governmental organizations, regulators, and other stakeholders involved in the management of
oxygen systems.

Background
Medical grade oxygen with purity over 90% is a colorless, odorless, and tasteless gas that is
required in every health care setting and is used for resuscitation and inhalation therapy. It can be
used for medical conditions such as chronic obstructive pulmonary disease (COPD), cyanosis,
shock, severe hemorrhage, carbon monoxide poisoning, trauma, cardiovascular and respiratory
arrest, resuscitation, and life support. It is generally stored as a compressed gas in cylinders.
Medical oxygen cylinders have a white shoulder and black body as depicted in the figure.
The cylinders are filled at a gas manufacturing plant that manufactures oxygen using cryogenic
distillation process, also known as liquid medical oxygen (LMO) process or using pressure swing
adsorption (PSA) and transported to health facilities to be connected to manifold systems (groups
of cylinders linked in parallel as shown in the following figure 2) that are piped to areas of the
health facility; or to be used directly within patient areas. The cylinders are also refilled at LMO-
based re-fillers that procure oxygen from LMO manufacturers. The manifold unit consists of a)
control panel, b) right and left bank of oxygen cylinders, and c) stand-by arrangement
(emergency supply manifold). While less common, cylinders can also be filled using a PSA
oxygen plant that is co-located in a health facility and has a high-pressure compressor for
cylinder filling purposes. These cylinders require several accessories and fittings to deliver
oxygen such as pressure gauges, regulators, flowmeters, and, in some cases, humidifiers.
Cylinders also require periodic maintenance, commonly provided by gas suppliers at the point of
refilling.
Types of Oxygen Cylinders
Oxygen cylinders are of different sizes. Cylinder sizes for medical gases are named
alphabetically, unlike industrial cylinders, which are numbered. In India, most commonly used
cylinders are D type (jumbo) and B type (portable) cylinders which contains gaseous oxygen.
Type of oxygen Gas capacity in Capacity in cubic Water capacity Cylinder pressure Weight of oxygen
cylinder liters meters (m3) (liters) when full gas (kg)
Type D 7000 7 ~47L ~150bar ~9
Type B 1500 1.5 ~10L ~150bar ~2
Type A 750 0.75 ~5L ~150bar ~1
Labelling an Oxygen Cylinder
Medical gas cylinders are required to be labelled as the primary means of identifying the
contents of the cylinder. The color of the cylinder is only a guide. Labels for gas cylinders can be
reduced in size and shape to the dimensions specified in International Organization for
Standardization (ISO) 7225 – Gas Cylinders – Precautionary Labels.
 Diamond hazard label: This label displays the primary hazard with additional hazard
labels that highlight any subsidiary hazards. These labels display the dangerous goods
classification number.
 UN number: This label is preceded by the letters UN. The UN number is a number
assigned by the United Nations Committee of Experts on the Transport of Dangerous
Goods. The UN number for compressed oxygen is UN 1072.
 Proper shipping name.
 Product name (may be omitted if the proper shipping name is identical).
 Signal word, hazard and precautionary statements.
 EC number (if applicable).
 Package size and pressure.
 Company name.
 Address of the gas company.
 Additional company information.
 Contact telephone number.

Procedure
• The hospital should always take medical gases supply only licensed agencies. Industrial oxygen
must never be used in the hospital.
• To avoid capital cost, the hospital should make arrangements with the gas agency for supplying
their own cylinders, which in any case are rotated. Empty cylinders are given back and filled
cylinders are received.
• If cylinders are purchased by the hospital, a register with serial numbers of all the cylinders
should be maintained. The hospital authorities through manifold technician will ensure that the
empty cylinders are not exchanged from other cylinders. But their own cylinders are filled and
brought back to the hospital.
• At the time of purchasing a new cylinder, always insist on Explosive Certificate/Fitness
Certificate from the regulatory authorities.
• These cylinders should be sent for inspection periodically as specified by the gas agency.
Inspection certificates should be preserved.
• Individual oxygen cylinder should not be used without properly fitting with oxygen therapy
accessories such as oxygen regulator, flow meter, and humidifier.
• Oxygen cylinders should be checked for pressure of gas in it. Fix the pressure gauge in the
cylinder and check the pressure. The pressure specified for oxygen full cylinder is 137 bar.
Anything below 125 should be rejected/returned.

Installing a Cylinder
• Ensure the quality of the oxygen is assured, either by supplier quality certificate, PSA plant
logbook, or onsite analyzer testing.
• Oxygen cylinders should be prepared for use and set up in a secure position; vigilance by the
operator during preparation is critical.
• Tighten all the connections (between the cylinder and the regulator and between the regulator
and the flowmeter) so that oxygen does not leak.

• Before assembling regulators and fittings, it is extremely important to ensure there are no
particles of dirt in the cylinder outlet. Use clean compressed air or nitrogen to blow out any loose
particles of dirt from the valve sockets.
• Where clean compressed air or nitrogen is not available, particles of dirt and residual moisture
can be removed by quickly opening and immediately closing the valve (otherwise known as
“snifting”).
• No one should attempt to connect a regulator and/or accessory equipment using improvised
hookups or adapters. Plastic tape should not be used on a regulator.

Using a Cylinder

• All gas cylinders should be equipped with a functioning gas regulator while in use and a valve
opening key should be kept nearby for timely opening/closing of the valve.
• Check the contents gauge on the cylinder before starting to ensure that there is enough gas
available. Open the regulator and check the amount of oxygen in the cylinder on the pressure
gauge. If the needle is in the red zone, the cylinder is nearly empty and should not be used.
• Valve protection caps are required on all cylinders that are threaded to accommodate a cap
unless the cylinder valve is connected for use to a regulator or manifold.
• When the personnel have finished using a compressed gas cylinder, the cylinder valve should
be closed and the pressure in the regulator and associated equipment released.
When to Change a Cylinder
• Check your pressure gauge on the regulator unit (or control panel in case of jumbo cylinders
connected to manifold) often to make sure you do not run out of oxygen. Please be aware that
some manifold systems may have a sound based-alarm system to alert low supply of oxygen in
the cylinder.
• Always check the gauge (or control panel) when the valve is turned on.
• When the needle gets closer to zero on the gauge (or the pressure reading is low on control
panel), it is time to change the cylinder.
• Be sure to change the cylinder before the needle gets below 56 psi (4 bar).
• If the pressure gauge is broken, please note the weight of an empty and a full cylinder.
Regularly note the weight of a cylinder to ensure it is empty before changing it.
How to Change a Cylinder
• Turn off the oxygen flow:
 Using the cylinder wrench (spanner/key), turn the cylinder on/off valve clockwise to
close it.
 Bleed off the pressure in the valve by opening the flow regulator knob.
 When the gauge reads zero on the regulator, turn the flow regulator knob to zero.
• Change the cylinder:
 Remove the regulator unit (including pressure gauge and flowmeter) from the empty
cylinder and attach it to a filled cylinder.
• Turn on the oxygen flow:
 Place the cylinder wrench on the cylinder’s on/off valve, located at the top of the
cylinder.
  Open the valve by turning it anti-clockwise one full turn. As the valve opens, the
gauge on the regulator will show the amount of pressure in the cylinder. Pressure in a
full cylinder will read about 1680-2100 psi (120-150 bar).
 Adjust the flow knob on the regulator until the gauge reaches the flow rate your
doctor prescribed.
Oxygen cylinders should have a labelling tag stating its status – Full or Empty or In-use. The
“date of service” should also be mentioned on the cylinder. Ideally, the cylinders should be
periodically checked once every five years and the “date of test” should be stamped on the
cylinders.
Expiry of Oxygen Cylinder:
A full cylinder, if not used, expires in three years. After three years, the cylinder should be
emptied, and fresh volume of oxygen gas should be filled.

Handling a Cylinder

• It is observed that oxygen cylinders are transported by rolling them on the ground. This
procedure is wrong and compressed gas cylinders should always stay upright.
• Cylinders must always be secured to a trolley when being transported.
• Never roll, drag, or drop cylinders or place them in a way that they strike each other.
• Oxygen cylinders should always be securely restrained to prevent them falling over.
• Oxygen cylinders should be chained to prevent it from falling in storage areas.
• All gas cylinders must have caps over their valves. The valves should be capped (even if the
cylinder is empty) when the cylinders are not in use to protect it from damage that might cause
leakage. The valve is the most fragile part of a cylinder.
• Empty cylinders should be kept separated from filled ones.
• Cylinders must always be kept away from combustible materials.
• Cylinders should be stored in well-ventilated areas.
• Smoking should be strictly prohibited near cylinder storage areas and ‘No Smoking’ signs
should be clearly placed.
• Cylinders should be transported with care as a broken valve will result in the cylinder shooting
away like a rocket, which might cause injuries or even death. Trolley should be used for
maneuvering.
• Proper handling of compressed gas cylinders must be known to all hospital personnel. Regular
trainings should be conducted for the hospital staff.
• Ensure that the cylinder/gas is the right one for the intended use.
• Oxygen cylinders should always be used in a vertical position, unless specifically designed to
be used otherwise.
• Wear appropriate personal protective equipment such as safety shoes and safety spectacles.
Initial Safety Checks
• Medical oxygen cylinders must be inspected and pressure tested every five years by an
accredited cylinder test house.
• Medical oxygen has an expiry period of three years. Cylinder test periods and medical oxygen
periods must be kept inline.
• Ensure that hands are clean before handling the cylinder. If moisturizers or sunscreen have
been used, ensure hands are dry before handling.
• If alcohol-based gel or liquid have recently been used, ensure it is totally evaporated before
oxygen use.
• When selecting a cylinder for use, ensure it is clean and dry without any oil or grease on it and
it should be free from any damage.
• Check the connection for leaks using the following procedure: o Leakage will be revealed by
either hissing or, in the case of fuel gases, by an odor. Do not test for leaks with a naked flame.
o Close valve, remove connection, check, and refit.
o Never use excessive force when connecting equipment to cylinders.
o If leak persists, label cylinder and return to BOC or concerned agency.
• Do not use any cleaning material that may contain chlorine or ammonium as they may cause
damage to the cylinder package. If any contact with salt water has occurred, then cylinder should
be rinsed with fresh water.
• Do not deface or remove any markings, tags, or stencil marks used for identification of contents
attached by the gas vendor.
• In case of empty compressed medical oxygen cylinder, ensure the following:
o Use moderate force to close the cylinder valve and release the pressure in the regulator or
tailpipe. o Valve outlet cap, where fitted, is replaced.
o Empty cylinders are immediately returned to the empty cylinder store (dry place/room) for
return to BOC Service or concerned agency.
• Compressed medical oxygen cylinders are moved with an appropriate size of handling device.
• Handle with care. The cylinder should not be knocked violently or allowed to fall.
• Do not use the cylinder in the vicinity of persons smoking or near naked lights.
• Always check service/expirer dates before use.

General Safety Considerations

• Personal protective equipment such as eye and hand protection, should be worn when handling
oxygen cylinders.
• All compressed medical oxygen gas cylinders (regardless of size) should be secured to racks,
walls, work benches, or hand trolleys by a strong chain or strap, capable of preventing the
cylinder from falling or being knocked over.
• Cylinder should be securely placed in a cylinder trolley in an upright position by the patient
bedside to prevent it from accidental falling. Note that small cylinders, when used for patient
transport, may be laid flat, but still need to be firmly secured.
• Do not drop cylinders or allow sharp impacts on cylinders.
• Cover the top of the oxygen cylinder with the cap when it is not in use or when being
transported for delivery.
• Set up the cylinder for patient use a safe distance from the patient.
• After connecting the appropriate equipment, turn the flow control off. Carefully open the main
valve, then turn up the flow slowly to the desired rate.
• Do not place the cylinder on a patient’s bed.
• Before moving cylinders, they must be disconnected from any regulators or manifolds. Apply
any protective valve caps before the cylinders are released.
• Cylinders should be moved only on a hand truck or other cart designed for handling gas
cylinders. • No more than one cylinder should be handled at a time except on carts designed to
transport more than one cylinder.
• All medical gas cylinders should be clearly labelled to identify the contents. A cylinder without
a readable product label should not be used and should be returned to the supplier.
• All defective gas cylinders or equipment should be reported immediately to the supplier for
correction or replacement.

Fire Safety Considerations

• Ensure appropriate fire extinguishers are kept nearby and are regularly inspected.
• Keep oxygen cylinders at least several meters from a heat source, open flames,
electricaldevices, or other possible sources of ignition.
• Put a “No Smoking” sign near oxygen sources in the hospital.
• Check that all nearby electrical circuit breakers and devices are in safe working condition and
free from sparking to prevent a serious fire occurrence.
Hazards Classification Labelling and Packaging Regulations – Danger
• May cause or intensify fire; oxidizer (H270).
• Contains gas under pressure; may explode if heated (H280).
• Keep/Store away from clothing, hydrocarbons and combustible materials.
• Keep reduction valves free from grease and oil and from sand and dust too.
• In case of fire, stop leak if safe to do so.
• Protect from sunlight: store in a well-ventilated area.
• Contact with combustible material may cause fire.
• Keep out of the reach of children.

Fire Fighting Measures

In case of fire,
• If it is safe to move the cylinders, then:
o Close the cylinder valve to stop the flow of product.
o Move the cylinders away from source of heat.
• If it is not safe to move the cylinders, then:
o Use water and fire extinguishers from a protected position
All types of fire extinguishers may be used when dealing with a fire involving medical oxygen
cylinder. Fire and rescue team should be informed that medical oxygen cylinders are present
inside the building and share their location.
Exposure Controls
• Adequate ventilation must be ensured when using medical oxygen cylinders.
• If clothes get impregnated with oxygen (due to leak), stay away from source of ignition or open
flames. Clothing impregnated with oxygen should be advised to ventilate in fresh air for up to 15
minutes.
Disposal Considerations
It is recommended that medical oxygen cylinders should not be vented after use; they should be
returned to BOC, with any residual gas*, where they will be vented before refilling in a safe
environment. This is done due to the possible chance of moisture being entrapped into the
cylinder.
Storing a Cylinder
• Oxygen cylinders should not be stored for excessive periods of time. Only purchase sufficient
quantities to cover short-term needs.
• Properly secure the cylinder at all times: straps, belts, or chains.
• Always physically separate full and empty medical gas cylinders. Ambulatory organizations
can do this by using separate racks, physical barriers or by color coding the storage rack.
• Label the cylinders clearly (open/empty or full/unopened) to avoid confusion and reduce delay
while selecting between full, partial, and empty cylinders.
• Store in well-ventilated, clean, dry conditions, not exposed to extremes of heat or cold.
• Oxygen cylinders should be stored away from sources of ignition, other flammable materials.
• Protect cylinder and all other fittings from contamination by oil and grease.
• Never use a single-use and/or re-use an industrial gas cylinder for refilling medical oxygen.
• Store oxygen cylinders securely when they are not in use and should be properly restrained.
• PESO license is required to store more than 200 cylinders at a facility.
Transporting a Cylinder
• Use cylinder trolley when handling gas cylinders.
• Fit suitable protective valve caps and covers to cylinders before transporting.
• Transport cylinders with valve caps.
• Do not lift cylinders by the cap.
• Do not transport with the regulator attached.
• Cylinders must be fastened securely in upright position.
• Cylinders must be located in a compartment separated from the driver.
• Ensure all cylinders are adequately restrained.
• The vehicle must be adequately ventilated, and the load be secured. Signs should be carried on
the outside to inform the public of what is being carried. Ensure that the driver is aware of the
potential hazards and the detailed information sheet is carried and understood in the event of any
emergency.
Roles and Responsibilities of Hospital Staff

Duties of Supervisor
• To ensure that relevant staff receive appropriate training specific to the compressed gases they
are handling and using.
• To ensure that compressed gases are used only for the intended purpose and in accordance with
defined procedures and rules.
• To ensure that applicable Safety Data Sheets (SDS), Emergency Response Plan (ERP), or other
relevant literature is made readily available to staff.
• To provide staff and visitors with appropriate personal protective equipment (PPE).
• To provide appropriate supervision to staff.
• To ensure staff and visitors adhere to applicable occupational health and safety regulations for
the use of compressed gases.
• To investigate reported incidents to determine the cause and to develop appropriate
preventative measures to minimize a recurrence.
• To maintain appropriate records pertaining to the handling and use of compressed gases
including an up-to-date inventory, training records, and reported incidents.
Duties of Staff
• To adhere to defined procedures and rules and applicable occupational health and safety
regulations for the use of compressed oxygen gas.
• To wear and maintain the personal protective equipment.
• To ensure the use of correct medical gas and that it is used within its expiry date (found on
batch label of the cylinder).
• To check for enough oxygen in the cylinder using gauge and valve on the cylinder.
• To remove the tamper evident seal and cover that is fitted over the valve outlets.
• To ensure that the flow selector is set to zero before using the (black) hand wheel to open the
cylinder valve.
• To open the cylinder valve slowly (turn anti clockwise until it stops) and check for any leak.
• To ensure the outlet (fir tree connector) is free of obstruction. If any dirt or other obstruction is
seen, slowly turn the flow dial to maximum to clear it.
• To ensure that the correct equipment is selected for connection to the cylinder.
• To connect tubing to the fir tree connector and select appropriate flow rate.
• To turn off the valve turned off, when not in use, using only moderate force.
• To notify their supervisor of identified hazards related to the use of compressed oxygen gas.
• To notify their supervisor of any incident related to the use of compressed oxygen gas.
Duties of Manifold Operator
• To ensure that all the cylinders in the Manifold Room are OK every morning.
• To open the required number of cylinders to ensure the correct pressure in the pipelines.
• To use the cylinders from one side of the manifold cylinders bank (right sight or left side). The
cylinders of the other side should be sent for refilling as soon as all the cylinders of that bank are
empty.
• To check all cylinders for leakage using soap water mixture.
• To maintain a stock of required tools with him in the manifold room.
• After checking the manifold room, the staff should take a round of the hospital to check all the
outlets, and to ensure their proper functioning from staff posted there.
• To repair or arrange to repair any defects in the outlets or in the pipeline including main
manifold room.
• To place order for refilling of the cylinders in consultation with the authorized officer.
• To ensure supply of oxygen in other areas without central pipeline.
• To help the operation theatre technician in maintaining the Boyle’s machine.
• To change the ward’s cylinder.
• To report all the major problems to the administrators immediately.

Duties of Safety Resources

• To provide information and advice in health, safety, and environmental protection including on
the safe use of compressed gases.
• To develop and administer health, safety, and environmental programs.
• To provide health and safety training.
• To provide hazardous waste disposal services.
• To respond to reported incidents and spills of hazardous materials.
• To support regulatory compliance.

User Care and Preventive Maintenance of Cylinders

The User provides daily and weekly routine maintenance of oxygen cylinders and associated
accessories. However, preventive maintenance of the cylinders should be carried out periodically
(every 5 to 10 years) by the gas supplier, and a colored cylinder test ring may be fitted around the
cylinder neck indicating the next due date for testing. The User should be done the following
activities daily and weekly.
 Cleaning: Ensure delivery tubes and masks are decontaminated. If humidifier bottle is
used, disinfect and refill with clean water.
 Visual check: Check cylinder is correct type and correctly labelled. Check all parts are
fitted tightly and correctly.
 Function: Before use, ensure cylinder has sufficient pressure. Ensure flow is su fficient
for intended use.