PIPE DREAMS –
Don't Let the Patient Do Your Final Testing
Fred
Evans, CEO
Medical Gas Management, LLC
During
the final testing of medical gas systems, each outlet should be tested
for flow operation, leaks, gas and particulate purity. How confident are
you that each component has been included in your certification
process?
We have tested thousands of medical gas systems and millions of
medical outlets and inlets during our career. With all of this activity
we are proud to have detected hundreds of crossed lines. As we finish
each project and begin the paperwork, we continually reflect back to the
actual scope of the project and final test to ask ourselves, “Have
we tested everything?” I would like to cite three cases that caused
us to re-evaluate and change our procedures.
Case I
After a successful small medical gas certification involving
a remodel of 3 oxygen, 3 medical air and 3 vacuum inlets/outlets, the
hospital called with concerns that various medical gas outlets
didn’t work. These outlets/inlets were not in the area of remodel. A
return trip to the facility and investigation revealed what actually
happened.
The “As Built” drawings were not correct.
The existing medical gas zone valve had actually been relocated
which meant that the entire floor had been shut down. We had no knowledge
of this.
Lines above the ceiling had been capped. New remodel draw-ings
did not show demo of the
existing lines.
We were called for final certification of Rooms 1, 2, and 3,
without the contractor present and without a clear understanding of the
project. We did not know that three corridors away, one side of the ICU
had been eliminated because the wrong lines were capped.
This incident reinforces the concept that additional rough-in
inspection, testing, and documentation are a vital link to the final
certification.
Case II
One year after final certification of a new facility we were
called with concerns of a crossed line in the pulmonary exam room. On
site investigation revealed:
Original plan did not include outlets in this room.
A change order was issued to add outlets to the room before or at
the same time as the certification was being done.
The area had undergone a rough-in inspection and the paperwork
identified the rooms and outlets/inlets served by the zone valve. This
documentation had been sent to the office so the technician could not
compare it with the actual count of outlets. He assumed the room did not
have outlets because the plans did not show them. The result was that a
crossed line happened in that room. Once again, there was no patient
incident, but it was possible.
As a result, we perform final testing only after all
modifications have been made and we are confident that we understand all
applicable changes to the design.
Case III
I received a call from a general contractor with concerns of
a possible crossed line in an operating room that was in use. I was
nearly 1,000 miles away and knew I couldn’t get to the facility. I
dispatched two technicians from our corporate office, and using a private
plane, they arrived at the facility within two hours of my being notified
of a potential problem.
The facility was undergoing a multi-phased addition and remodel.
The operating rooms were included in the project. Gases involved were
oxygen, medical air, nitrous oxide, nitrogen, carbon dioxide and
vacuum.
One of the procedure rooms experienced problems during anesthesia
using nitrous oxide. The room had been in use for several months but only
two cases involved nitrous oxide induction; both cases had been cancelled
or postponed. Our investigation revealed that the room in question did,
in fact, have a crossed line. This is the account of what happened.
The O.R. project was done in phases. The room in question was
isolated by ceiling isolation valves, oxygen, nitrous oxide, carbon
dioxide and vacuum lines piped over a large air duct. The installing
contractor labeled the pipe incorrectly; nitrous oxide was labeled carbon
dioxide and carbon dioxide was labeled nitrous oxide. Both lines were the
same size. To complicate the issue, spray installation covered most of
the pipe. At the point of crossed lines, the tubing dropped down to the
zone valve box. In the zone valve box were the two 1/2 inch valves for
nitrous oxide and carbon dioxide. They were also mislabeled as they left
the zone valve box. The pressure gauges read 53 psig on both lines. Above
the ceiling, over the operating room, the line marked carbon dioxide was
capped. The line that terminated at the wall outlet was marked nitrous
oxide.
This system did not have a rough in inspection or a rough-in
cross line test during construction. The original technician went to the
zone valve marked nitrous oxide and closed the valve. He then tested the
outlet using an oxygen analyzer. At that point he lost both
pressure and oxygen concentration and logically assumed it was a
nitrous oxide outlet. Both carbon dioxide and nitrous oxide have 0%
oxygen; they appear to be the same.
This was clearly a close call. Though no patients were injured,
it provided a valuable lesson. Our procedures have changed to include a
gas specific analyzer on every future project.
These incidents demonstrate the need to pay close attention while
testing, to understand the project’s scope and specifications and to
maintain a never-ending concern for patient safety.
|
|
License Enforcement to Begin in Louisiana
Don
Traylor, Executive Director of the State Plumbing Board of Louisiana
announced that effective November 1, 2000, the state will begin
enforcement of the Medical Gas and Vacuum Systems Verifier license.
Act 1020 of the 1999 Regular Session of the Louisiana State
Legislature established license requirement for Medical Gas and Vacuum
Systems Verifiers as defined in LA R.S. 37: 1367 (H).
Additional information or an application can be obtained by
calling the New Orleans office at: (504) 826-2382.
Tom Evans, President of the Medical Gas Professional Healthcare
Organization commented that he is pleased the State of Louisiana has
recognized the vital role of medical gas systems in providing quality
healthcare. “The State legislated license requirement, coupled with
the MGPHO credential requirement in the State of Louisiana, is a
significant step in assuring patient safety in medical gas
systems.”
|
|
MGPHO
Members to Meet in Kansas City
Members of
the Medical Gas Professionals Healthcare Organization will
gather January 18 and 19, 2001 for their semi-annual meeting in Kansas
City,
Missouri.
The meeting will be held at the Sheraton Suites Country Club
Plaza at 770 West 47th Street, Kansas City. Al Moon is in charge of
meeting reservations. Cost to MGPHO members is $40.00; non-members cost
is $75.00 for the meeting and lunch. Hotel reservations are available by
calling 1-800-227-2416 before December 18, 2000. Be sure to mention MGPHO
when making reservations to receive the special rate of $127.00 (plus
tax) per night. Complete details are available on the MGPHO web site at:
www.mgpho.org.
In addition to the meetings, members can enjoy many local
attractions including fine restaurants and that great KC Barbeque,
shopping at the Country Club Plaza, historic Westport and the Truman
Library, the Nelson Atkin Museum of Art and for those feeling lucky,
Riverboat Casinos.
Make plans now to be educated and entertained at the January
MGPHO meeting in Kansas City.
|
|
Installer's School Schedule for 2001
Make
2001 the year you increase you knowledge of medical gas systems and
become a qualified medical gas installer. MGM’s Installer’s
School schedule for 2001 is as follows:
January 31, February 1 & 2
March 28, 29 & 30
May 16, 17 & 18
July 25, 26 & 27
September 19, 20 & 21
November 14, 15 & 16
Classes are held at the MGM Education Center in Bethany,
Oklahoma. Space is limited. Register online at www.mgmusa.com or call Jan at 800.732.9035 for
information.
|
|
Meet
the Staff
Sue Pittard
Sue Pittard began her career
with Medical Gas Management on a part-time basis in August 1992. That
part-time position turned into a full-time career with Sue’s
acceptance of new responsibilities and increasing involvement in the
management of the company. In January 2000 she was named Vice President
of Administration.
The most challenging part of her job would have to be scheduling.
Sue not only keeps up with Fred and Tom Evans’ busy calendars, she
is responsible for scheduling the work for all of the MGM/SEI
technicians. To accomplish this task, she must deal with hospitals and
contractors, have an understanding of what each job requires, consider
who is best qualified to handle it and put the plan in motion. Keeping
track of 21 technicians across the country is a demanding task, but
Sue’s patience and skill make it seem easy.
Sue relates that the stories techs come home with always provide
a chuckle. She says, “We are able to laugh at ourselves for the some
of the strange things that happen both on the jobsite and within the
corporate office. We have a fun “bunch” to work with and we
enjoy working together.”
What Sue likes best about her work is the variety. Each day holds
something new and different, and there is never a lull or time to be
bored. Dealing with all the phone calls, project issues, staff, hospital
and contractors provides for a jam-packed day.
Responsibilities at MGM keep Sue very busy, but she finds time to
be involved at her local church where her husband, Wayne, is minister of
Pastoral Care and Senior Adults. She also enjoys attending soccer games
at Southern Nazarene University where her son Seth, a freshman is part of
the team, and cooking and entertaining friends at home.
The greatest pleasure Sue has is seeing the difference MGM makes
in the industry and knowing healthcare facilities are in good hands when
they call MGM for all their medical gas needs.
|
|
Beyond
The Walls…
This medical air pipe was joined using flux and a soft
solder connection. Although the joint appears to be sound, it is not in
compliance with NFPA 99. Here's Why:
1. The use of flux when
making a connection contaminates the system.
2. The melting point of soft solder is 450º. The
minimum melting point of BCuP filler metals is above 1300º.
3. Should a fire occur in a facility, one would hope to keep
the
medical gas system intact as long as possible. With a melting
temperature above 1300º, the brazing filler metal will protect the
system for a longer time period.
Be sure that installation and repairs to your medical gas system
are
brazed using the proper techniques and materials.
|
|
