1.26 Safety Standards for Medical Gases
Category: UWHC Patient Care Policy
Effective Date: April 1, 2017
Manual: Respiratory Care Services
A. Medical gases come in high-pressure gas cylinders or cryogenic liquid containers. Oxygen is the most
common medical gas and is frequently used for patients with respiratory insufficiency or on life support
equipment. Other gases used by Respiratory Care (RC) are helium, nitric oxide, and medical grade air.
B. RC will adhere to American National Standards Institute (ANSI) and National Fire Protection
Association (NFPA) standards regarding any aspect of the care, delivery, storage, handling, or
administration of medical gases by its personnel.
A. An oxygen-enriched atmosphere will accelerate combustion.
B. Static discharges, sparks, open flames, and other sources of ignition become significant hazards.
C. Gases stored in cylinders are under very high pressures, potentiating explosive hazard.
D. Large gas cylinders or liquid reservoirs are very heavy and bulky and can cause personal injury or
property damage if improperly handled.
E. Rapid opening of cylinder valves can cause sudden increase in downstream gas pressure and temperature
caused by the adiabatic heat of recompression.
A. Compressed Gas Cylinders and Connections.
1. All gas cylinders will be secured (fastened to cart, bed, wheelchair, etc.) at all times.
2. Cylinders are not allowed in MRI.
3. Gas cylinder contents must be identified prior to patient use as delivery of the wrong gas to a patient
could cause injury or death.
4. Gas cylinders will not be placed close to sources of heat, which could lead to an explosive hazard.
5. Oxygen containers, valves, regulators, hose and other oxygen apparatus shall be kept free from oil and
6. Caps will be kept on large cylinders that are being stored and are not on standby for use.
7. Care will be taken when opening cylinder valves.
8. Large cylinders should be opened briefly before attaching the regulator to purge any debris in the valve.
9. Cylinders will be maintained in accordance with DOT regulations and specifications.
B. UW Health - UH- AFCH does not utilize or support trans-filling of liquid oxygen portable systems.
C. Bulk Medical Gas System.
1. It is the responsibility of the contracted vendor to maintain the bulk liquid oxygen system in accordance
with all existing regulations and specifications.
2. It is the responsibility of University Hospital Facilities and Engineering Services to maintain the bulk
oxygen piping system and compressed medical air piping system in accordance with all existing
regulations and specifications. Contact University Hospital Facilities and Engineering Services (263-
5205) for any problems with gas or damages outlets.
A. Facilities and Engineering Services Department Policy # EC.02.05.01 EP2-4, EC.02.05.05 EP1,3-5: “Utility
Equipment Management System.”
B. Administrative Policy #12.25: "Hazardous Materials, Gases, and Radioactive Materials".
C. Guidelines from Administrative Policy #12.64: “UW Health Environment of Care Safety Program Policy.”
D. Facilities and Engineering Services Department Policy # EC.02.05.09 EP1-3: "Testing and Installation of
Medical Gas and Vacuum Pipeline Systems".
E. "Standard for Health Care Facilities" (NFPA 99), National Fire Protection Association, Inc.
Approved by Director and Medical Director of Respiratory Care