National Patient Safety Alert: Use of oxygen cylinders where patients do not have access to medical gas pipeline systems

Summary

During periods of extreme pressure, often exacerbated by a surge in respiratory conditions, demand on supplies of oxygen cylinders, especially the smaller sizes, increases in the NHS due to the need to provide essential oxygen treatment in areas without access to medical gas pipeline systems.

This surge in demand increases the known risks associated with the use of oxygen gas cylinders, and introduces new risks, across three main areas:

• patient safety
• fire safety
• physical safety

A search of incidents reported to the of the National Reporting and Learning System (NRLS) and Learn from Patient Safety Events (LFPSE) service in the last 12 months identified 120 patient safety incidents, including those with these themes:

• cylinder empty at point of use
• cylinder not switched on
• cylinders inappropriately transported
• cylinders inappropriately secured

Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest.

In addition there is a need to conserve oxygen cylinder use to ensure a robust supply chain process.

As a result of current pressures on the NHS, NHS England issued providers with a summary of best practice guidance on the ‘Safe use of oxygen cylinders’ on Friday 06 January 2023 to support providers to optimise and maintain the safe use of oxygen cylinders. This guidance was issued via the Patient Safety Specialist and Emergency Preparedness, Resilience and Response (EPRR) networks.

Actions

To be completed as soon as possible, and not later than 20 January 2023.

1.  The chair of acute trust medical gas committee, working with key clinical/non-clinical colleagues including the local ambulance trust, should review the NHS England ‘Safe use of oxygen cylinders’ best practice guidance and ensure a risk assessment is undertaken in all areas where patients are being acutely cared for (either temporarily or permanently) without routine access to medical gas pipeline systems. 

Risk assessment should pay particular attention to:

• avoiding unnecessary use of cylinder oxygen and excessive flow rates by ensuring oxygen treatment is optimised to recommended target saturation ranges.
• ensuring safe use of oxygen cylinders by clinical staff including;

- safe activation of oxygen flow

- initial and ongoing checks of flow to patient

- initial and ongoing checks of amount of oxygen left in the cylinder - especially during transfer or whilst undergoing diagnostic tests.

• fire safety, including:

- appropriate ventilation (both in physical environments and in ambulances),  safe storage of cylinders physical safety, including:

- awareness of manual handling requirements

- safe transportation of cylinders using appropriate equipment

- safe storage of cylinders.

2. Once the risk assessments have been undertaken, convene the acute trust medical gas committee as soon as possible to review the findings of the risk assessments and formalise an action plan. Ensuring that the committee has executive director representation and ambulance trust input.