NFPA requires periodic or regular inspection and testing of piped medical gas systems. The NFPA 99 is the most respected document regarding medical gas systems in the US, and it has been adopted by all 50 states. Therefore, facilities typically follow the NFPA recommendation for annual piped medical gas systems inspections.
CMS and TJC require a risk assessment using codes and manufacturer recommendations to determine the inspection and testing frequency.
Summary of Codes & Standards regarding Annual Inspection
NFPA “Required” Testing
- Central Supply Systems (e.g. Oxygen Bulk, Medical Air Compressors, Manifolds, Vacuum System): Inspected annually, maintained by a qualified representative, & record kept for the AHJ
- Periodic/Routine Testing & Inspections of Medical Gas & Vacuum Systems
- Alarm Testing - Audible & Visual Indicator Function
- Outlets & Inlet Performance (include flow & pressure)
- Medical Air, Vacuum, & WAGD Source Equipment
- PMs per manufacturer’s recommendations
- Annual Calibration of Carbon monoxide monitor
NFPA “Recommended” Testing
- Annual medical gas & vacuum systems survey – deficiencies corrected
- Included in survey per NFPA 99 A.5.1.15:
- Medical air source equipment
- Vacuum source equipment
- Gas manifolds
- Area & Master Alarms
- Zone valves
- Outlets & inlets
NFPA 99, 2018
Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets.
188.8.131.52.2.2* Inspection Schedules. Scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
184.108.40.206.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
220.127.116.11.5 A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be implemented.
18.104.22.168.7 Procedures, as specified, shall be established for the following:
(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer’s recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually or more often if recommended by the manufacturer
22.214.171.124.8 Audible and visual alarm indicators shall meet the following requirements:
(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.
126.96.36.199.9 Medical–surgical vacuum station inlet terminal performance, as required in 188.8.131.52.10.4, shall be tested as follows:
(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level
A.184.108.40.206.2.2 In addition to the minimum inspection and testing in 5.1.14, facilities should consider annually inspecting equipment and procedures and correcting any deficiencies.
The [organization] inspects, tests, and maintains medical gas and vacuum systems.
Note: This standard does not require [organization]s to have the medical gas and vacuum systems discussed below. However, if an organization has these types of systems, then the following inspection, testing, and maintenance requirements apply.
Rationale for EC.02.05.09
Medical gas and vacuum systems must be reliable. Testing these systems increases the likelihood of detecting reliability problems and reduces the risk of losing this critical resource.
Elements of Performance for EC.02.05.09
1 In time frames defined by the organization, the organization inspects, tests, and maintains critical components of piped medical gas systems, including master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. These activities are documented.
2 The organization tests piped medical gas and vacuum systems for purity, correct gas, and proper pressure when these systems are installed, modified, or repaired. The completion date of the tests is documented.
3 The organization makes main supply valves and area shut-off valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control.
CGA E.10-2013 Maintenance Schedule Recommendations
Annually – Bulk (switchover activation), pressure gauges with 5%, zone valves (leaks, labeling, clean), all outlets, source equipment inspections, & alarm activation
It is not required by NFPA 99 for individual room numbers to be listed. In the event of a fire, the Respiratory or Nursing staff must quickly determine the patients affected when the valve is shut.
Method “A”: 1024, 1025, 1026, 1027, 1028, 1029, 1030, 1031, 1032, 1033, & 1034
Method “B”: 1024-1034
In my opinion Method “B” is quicker for the employee to accurately determine the areas shut off during an emergency
* Zone valve labels are required to be visible from the outside of the enclosure (e.g. mounted above the assembly or on the metal tab provided inside the assembly visible through the cover). Labels may not be affixed to the removable cover.
Reference: NFPA 99, 2018, A.220.127.116.11.7 It is not intended that every room be listed on the label, but an area that is easily identifiable by staff needs to be indicated.
Divide the ACFM value by a factor of 2.73
At sea level 100 ACFM = 36.6 SCFM @ 19"Hg
Evergreen Recommends rotating dryers every month
- Odd Months use Dryer #1
- Even Months use Dryer #2
Dryer rotation procedure (example – Dryer #1 currently In-Use and #2 in Reserve):
- Open #2 inlet valve
- Open #2 outlet valve
- Change power selector switch to #2 dryer (turn power off to #1 and on to #2)
Note: Some dryers (Zander) have program timers that will require maintenance parts after 1 years service. By turning the power off to the dryer in reserve you’ll reduce these maintenance parts cost by 50%.
- Wait for both Dryer #1 columns to depressurize
- Close #1 outlet valve
- Close #1 inlet valve
When a medical gas or vacuum system is cut and brazed or a "major component" is replaced the system must be tested by a credentialed ASSE 6030 Medical Gas Verifier after it's re-pressurized before patient service.
A medgas repair that includes exchanging a like for like minor component does not require an independent ASSE 6030 verification, but does require a "function test" by respiratory therapy or maintenance. Repairs of gas specific components require cross-connection testing afterwards.