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Testing and Installation of Medical Gas and Vacuum Pipeline Systems (EC.02.05.09 EP1-3)

Testing and Installation of Medical Gas and Vacuum Pipeline Systems (EC.02.05.09 EP1-3) - Policies, Administrative, UWHC, Department Specific, Facilities & Engineering Services

EC.02.05.09 EP1-3

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
EC.02.05.09
EP1-3

Original
X Revision
Page 1
of 3
Title: Testing and Installation of
Medical Gas and Vacuum Pipeline
Systems


EC.02.05.09 EP1-3

I. PURPOSE:

This policy establishes procedures for installation, inspection and certification of new or
remodeled Medical Gas or Vacuum Distribution Systems in the University of Wisconsin
Hospital and Clinics. This policy also establishes procedures for the periodic inspection and
testing of these systems as part of the Building Maintenance program.

II. POLICY:

New Systems/Remodeled

Newly installed or remodeled Medical Gas or Vacuum Distribution Systems will be tested by a
certified individual other than the manufacturer or installer to the standards listed in the
appropriate edition of NFPA 99 prior to use for patient care. The Facilities & Engineering
Services mechanical trades supervisor must approve all medical gas outlets and components
used in construction and remodel projects prior to beginning installation.

Annual Inspection and Testing

Medical gas outlets will be tested annually. The test results are maintained by the
Maintenance and Operations Manager. Copies of testing and certification results will be
maintained in Facilities & Engineering Services project files and The Joint Commission
binders. Testing forms are maintained by the Mechanical Trades Supervisor.

IV. PROCEDURE:

A. Major or Minor Remodeling & Repair

Medical Gas Certified plumbers must install all medical gas systems. These plumbers
must present certification papers to the contract manager prior to beginning work on
the project. The Facilities & Engineering Services or Facilities Planning & Construction
project managers will keep a copy of these papers in the project file.
After installation or remodel of a medical gas or vacuum system, the system shall be
inspected and pass all testing as required by the appropriate edition of NFPA 99. The
system will be tested for purity, correct gas, and proper pressure. The installer will take
corrective action if this performance is not verified.

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
EC.02.05.09
EP1-3

Original
X Revision
Page 2
of 3
Title: Testing and Installation of
Medical Gas and Vacuum Pipeline
Systems


EC.02.05.09 EP1-3

After testing, the certification contractor will provide the Hospital with a Letter of
Certification and Inspection Report that indicates proper findings of all items listed
above. The Project Manager will review the letter and inspection report. Any items that
require repair or adjustment will be reviewed prior to turning the system over for patient
care. The Project Manager may determine that problems are severe enough to require
a recertification of the system after correction.
A copy of the inspection and certification will be permanently maintained in the
construction project records in the Facilities & Engineering Services Department and
The Joint Commission binders.
B. Preventive Maintenance
Medical Gas outlets are tested by Facilities & Engineering Services and Respiratory
Therapy as required by the appropriate revision of NFPA 99. Preventive maintenance
work orders are issued to conduct this testing. Results of these inspections are
maintained by the Maintenance and Operations Manager. The Utility Team reviews
and determines if an adjustment of the inspection frequency is required.
All Medical gas master signal alarms, area alarms, and pressure switches are tested
as required by the appropriate revision of NFPA 99. Master alarms are tested by
Medcon. Area alarms are tested by Facilities & Engineering Services.
All Medical gas shutoff valves are tested by Facilities & Engineering Services as
required by the appropriate revision of NFPA 99. Main supply valves and area shut-off
valves are accessible and clearly labeled.
All source equipment is tested by a manufacturer representative as required by the
appropriate revision of NFPA 99.
V. COORDINATION:
Continual Readiness Committee
Facilities & Engineering Services Utility Team
Equipment Manager, Respiratory Therapy Department
Equipment Manager, Anesthesia Department

VI. ATTACHMENTS: Medical Gas Outlets Testing Procedure EC.02.05.09 EP1-3
Medical Gas Alarm Panel Testing Form

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
EC.02.05.09
EP1-3

Original
X Revision
Page 3
of 3
Title: Testing and Installation of
Medical Gas and Vacuum Pipeline
Systems


EC.02.05.09 EP1-3

Medical Gas Valve Box Testing Form
Medical Gas Outlet Testing Form

Wayne Abbott
Director, Facilities & Engineering Services