1.25 Emergency Plan for Loss of Piped Gas Pressure
Category: UWHC Administrative Policy
Effective Date: September 1, 2015
Manual: Respiratory Care Services
Loss of gas pressure in either the oxygen or the air piping system of The University of Wisconsin Hospital and Clinics
(UWHC) is a serious emergency, potentially life-threatening to patients on mechanical ventilators powered by oxygen
and/or air, or to patients requiring high concentrations of oxygen, particularly on CPAP/BiPAP (constant or bi-level
positive airway pressure) to maintain their ventilatory needs. Despite safety back-ups, emergency gas pressure losses
occur due to causes such as human error, component failure, severe weather, fire or explosion.
A. The Clinical Science Center (CSC) Plant Engineering 24 hour operations (room D4/163, 263-5205) and
The American Center (TAC) Plant Engineering/Security 24 hour Operations (Room 0217,440-6666)
monitors gas pipe line pressures throughout the Hospital. During any loss of pressure event,
communication and liaison should be maintained with Plant Engineering.
B. In the event of an emergent loss of gas pressure in the medical air or oxygen piping systems, the role of
the Respiratory Care (RC) department is to support patients directly by using portable gas supplies to
maintain ordered oxygen delivery whenever possible.
C. Plant Engineering and Plumbing are responsible for repairing all breaks in the medical gas piping system
and for arranging for emergency bulk liquid oxygen supplies from the vendor.
D. The Plant Engineering Control Room and RC each have a key to the main shut-off valve in A4/2 in CSC
and the Pump Room 015 at TAC, and both must be present if the main valve would ever need closing.
1. The CSC valve also affects the oxygen supply to American Family Children’s Hospital (AFCH).
However, AFCH also has a main valve in E1/1 that would allow all of AFCH to be back-pressured and
isolated from UWHC.
2. The key for the lock securing the main oxygen line at UWHC is kept in the meal ticket box in
E5/485. The key at TAC is kept in the metal box in room 0209.
E. The RC department will maintain minimum stocks of large [H/K-tank] cylinders of medical oxygen and
air in D4/128 and small [E/D-tank] cylinders of oxygen in C5/115b and D4/128 at CSC. At TAC, these
are located in the Medical Gas Cage on the loading dock, outside, in front of room 015.
F. Emergency “H” cylinder contents will be checked annually by RC Equipment staff.
1. All emergency cylinders with less than 1000 psig will be replaced.
2. Regulator outlet pressure will be calibrated to 56 +/- 2 psig.
3. Damaged regulators will be repaired or replaced.
G. The charge therapist will notify the Administer on Call (AOC) immediately anytime we are
alerted of the loss of compressed gases. At TAC, the General Manager on call should also be
notified through paging. The AOC will help in securing enough gas supplies for the gas loss.
A. The CSC’s main liquid oxygen (LOX) is a 13,000 gallon bulk tank. It is backed up by a smaller liquid
reservoir of 1500 gallons. This system is located on the south side of building. TAC’s main liquid
oxygen (LOX) is a 3000 gallon bulk tank. It is backed up by a smaller liquid reservoir of 525 gallons.
This system is located on the west side of the Central Utility Plant (CUP) building.
B. The CSC’s medical air is provided by two independent high capacity systems. Each of these systems can
separately and independently provide adequate medical air to both CSC and AFCH. TAC’s medical air is
provided by redundant medical air pumps. Full back up capacity is provided and can provide adequate
C. The OR’s have extra E Walk-O2-Bout cylinders on the outdoor cylinder dock, if urgently needed at CSC
and at TAC in room 1381 in the OR.
D. Large oxygen tanks with cart, regulator, high pressure hose, and quick connect will be maintained in the
1. CSC Third floor: TLC B7/302, B7/303 (4 large oxygen tanks)
2. CSC Fourth floor: Neuro ICU F8/431 (3 large oxygen tanks)
3. CSC Fifth floor: ICU’s need to get tanks from D4/128.
4. AFCH PICU: 4425A (3 large oxygen tanks)
5. AFCH NICU: 8813A (3 large oxygen tanks)
6. CSC Cylinder Room: D4/128 (5 large oxygen tanks)
7. TAC Medical Gas Cage on loading dock, outside, in front of room 015 (2 large oxygen tanks).
E. Large medical air tanks with cart, regulator, high pressure hose, and quick connect will be maintained in the
1. AFCH PICU: 4425A (one large medical air tank) for Oscillator ventilator
2. AFCH NICU: 8213A (one large medical air tank) for Oscillator ventilator
3. CSC Cylinder Room: D4/128 (3 large medical air tanks)
4. TAC Medical Gas Cage on loading dock, outside, in front of room 015 (one large medical air
5. Each tank of emergency compressed gas will have a regulator pre-set to 55 +/- 2 psig.
A regulator pressure of 55 psig is needed to maintain a line pressure close to 50 psig.
A. The charge therapist must assess each situation considering:
1. Priority: location of unstable patients. ICU’s and IMC’s, along with the ED and OR are generally
2. Monitoring: Assemble the staff and equipment to maintain pressure and FiO2 for patients as
B. The following steps can be taken for rapid pressurizing of the oxygen piping system.
1. Acquire large cylinders with regulators and high pressure hose with quick connects from the
nearest storage area.
2. Connect to the oxygen outlets.
3. Open the valve on the large cylinder.
4. Close the zone valve to that area.
5. The system will be "back pressured" at standard pressure: 50 +/-3 psig.
6. Monitor cylinder pressure and replace cylinders when they get to 300 psig.
7. Connect the replacement gas cylinder to the wall outlet and turn on prior to removing the
8. Cylinders will run out faster in areas of high use. Two to three cylinders may be needed.
C. If the hospitals are experiencing a building wide oxygen pressure loss, close the zone valves to all ICU's
and ventilator dependent areas. Connect the appropriate number of large emergency oxygen cylinders in
each ICU to maintain outlet pressures of approximately 50 psig. Monitor line pressure. Most ICU areas
have pressure gauges for each zone.
D. If a part of the hospitals are affected by loss of oxygen pressure, isolate those zones by closing zone
valves, then back pressure as many of the zones as practical. This will minimize the number of portables
needed for individual patients.
E. Use E-cylinders of oxygen for patients in areas that cannot be back- pressured.
F. If the CSC experiences loss of compressed medical air, large emergency cylinders of medical air are
available from D4/128, and at TAC in the Medical Gas Cage on the loading dock, outside, in front of
room 015, for patients who cannot tolerate 100% oxygen, or for areas of the hospital that may be back-
G. All mechanical ventilators (except the Oscillator ventilator) and air/oxygen blenders will continue to
operate on 100% oxygen in the face of loss of medical compressed air. The Oscillator ventilator requires
compressed air to provide cooling gas for proper operation.
Approved by Director and Medical Director of Respiratory Care:
A copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].