NFPA RECOMMENDATIONS FOR RETESTING AND MAINTENANCE OF NON FLAMMABLE MEDICAL PIPED GAS AND VACUUM SYSTEMS
1. CYLINDER SYSTEMS WITHOUT RESERVE SUPPLY Index
These systems should be checked daily to assure that proper pressure is maintained and that the changeover signal has not malfunctioned. Periodic retesting of the routine changeover signal is not necessary as it will normally be activated on a regular basis. (AN I/NFPA 99C-4.2. 1 [4-3.1.5])
2. CYLINDER SUPPLY SYSTEMS WITH RESERVE SUPPLY Index
These systems should be checked daily to assure that proper pressure is maintained and that the changeover signal has not malfunctioned. Periodic retesting of the routine changeover signal is not required. Annual re-testing of the operation of the reserve and activation of the reserve-in-use signal should be performed. (ANSI/NFPA 99C-4.2.2[4-3. 1.6])
If the switch has an actuating switch and signal to monitor the contents of the reserve it should be retested annually. (ANSI/NFPA 99C-4.2.3[4.3. 1.6.2]
3. BULK MEDICAL GAS SYSTEMS Index
Maintenance and periodic testing of the bulk system is the responsibility of the owner or the organization responsible for the operation and maintenance of that system. The staff of the facility should check the supply system daily to assure that the medical gas is ordered when the contents gauge drops to the reorder level designated by the supplier. Piping system pressure gauges and other gauges designated by the supplier should be checked regularly and gradual variation, either increases or decreases, from the normal range should be reported to the supplier. These variations may include the need for corrective action. Periodic testing of the master signal panel system, other than the routine changeover signal, should be performed. Request assistance from the supplier or detailed instruction if the readjustment of bulk supply controls is necessary to complete these tests. ANSI/(NFPA 99C-4.2.4[4-3. 1.7])
4. MAIN-LINE PRESSURE Index
The main-line pressure gauge should be checked daily to assure the continued presence of the desired pressure. Variation, either increases or decreases, should be investigated and corrected. (ANSI/NFPA 99C-4.2.5 [4-18.104.22.168])
5. MEDICAL AIR COMPRESSOR INTAKE LOCATION Index
Quarterly rechecking of the location of the air intake should be made to assure that it continues to be a satisfactory source for medical compressed air. (ANSI/NFPA 99C-4.2.6[4-3. 1.9.2])
6. MEDICAL AIR SUPPLY SYSTEMS Index
Proper fluictioning of the pressure gauge and high-water-level sensor should be checked at least annually. Check the receiver drain daily to determine if an excessive quantity of condensed water has accumulated in the receiver. (ANSI/NFPA 99C-4.2.7[4-22.214.171.124])
An important item required for operation of any medical compressed air supply system is a comprehensive preventive maintenance program. Worn parts on reciprocating compressors can cause high discharge temperatures resulting in an increase of contaminants in the discharge gas. Adsorber beds, if not changed at specified time intervals, can become saturated and lose their effectiveness. It is important that all components of the system be maintained in accordance with the manufacturer's recommendations. It is important that any instrumentation, including analytical equipment, be calibrated routinely and maintained in operating order. Proper functioning of the dew point sensor should be checked at least annually. (ANSI/NFPA 99C-4.2.8 [4-126.96.36.199])
7. WARNING SYSTEMS Index
When test buttons are provided with signal panels, activation of the audible and visual signals should be performed on a regular basis (monthly). (ANSI/NFPA 99C-4.2.9[4-188.8.131.52(b)])
Annual retesting of all components of warning systems, if it can be done without changing piping system line pressure, should be performed. (ANSI/NFPA 99C-4.2.16[4-184.108.40.206(a)])
8. CHANGEOVER WARNING SIGNAL - MANIFOLD OR ALTERNATING SUPPLY Index
As this is a routine signal that is activated and deactivated at frequent intervals, there is no need for retesting UNLESS it fails. If the reserve-in-use signal is activated because both units of the operating supply are depleted without prior activation of the changeover signal, it should be repaired and retested. (ANSI/NFPA 99C-4.2.10 [4-220.127.116.11(b)])
9. RESERVE IN USE WARNING SIGNAL Index
All components of this warning signal system should be retested annually... Audible and visual signals should be tested periodically during the year (monthly). (ANSI/NFPA 99C-4.2.11 [4-18.104.22.168(c)])
10. RESERVE SUPPLY LOW (DOWN TO AN AVERAGE ONE-DAY SUPPLY) Index
All components of these signal warning systems should be retested annually... If test buttons are provided, audible and visual signals should be periodically tested throughout the year (monthly). (ANSI/NFPA 99C-4.2.12[4-4.1.l.2(d)])
11. MEDICAL AIR MASTER ALARM PANEL Index
The medical compressed air system alarms... should be checked at least annually. (ANSI/NFPA 99C-4.2.13 [4-22.214.171.124(g)])
12. MAIN LINE PRESSURE GAUGE Index
This pressure gauge should be checked on a daily basis to assure proper piping system pressure. A change, increase or decrease, if noted, may give evidence that maintenance may be required on the line pressure regulator, and could thus avoid a problem. (ANSI/NFPA 99C-4.2.14[4-4. 1.1.4(a)])
13. AREA ALARM PANEL PRESSURE GAUGES Index
This pressure gauge should be checked on a daily basis to assure proper system pressure. A gradual change, increase or decrease, if noted, will give an indication of a developing problem that could be avoided by preventive maintenance. (ANSI/NFPA 99C-4.2.15[4-4. 1.1.4(b)])
14. SHUT-OFF VALVES Index
Shut-off valves should be periodically checked for external leakage by means of a test solution or other equally effective means of leak detection safe for use with oxygen. (ANSI/NFPA 99C-4.2.18[4-126.96.36.199])
15. STATION OUTLETS Index
Station outlets should be periodically checked for leakage and flow. Instructions of the manufacturer should be followed in making this examination. (ANSI/NFPA 99C-4.2.19[4-188.8.131.52])
GAS SYSTEMS PERFORMANCE CRITERIA AND TESTING
PATIENT GAS SYSTEM - TYPE I. Index
Inspection and testing shall be performed on all new piped gas systems, additions, renovations, or repaired systems, to assure the facility, by certification, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
Inspection and testing shall include all components of the system or portions thereof including, but not limited gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, station outlets, and terminal outlets.
All systems that are breached and components that are subject to additions, renovations, or replacement shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipe line intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems, subject to inspection and testing, shall be all the new and existing components in the immediate zone or area that is located upstream an downstream of the point or area of intrusion.
Inspection and testing reports shall be certified and submitted directly to the responsible facility authority. These reports shall contain detailed listings of all findings, results, and any corrective actions that may have been~successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Responsible facility authority shall review inspection and testing records prior to use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlets is that shown on the outlet label and that the proper connecting fittings are checked against their labels. (ANSI/NFPA 99 4-5.1.1)
1. INSTALLER PERFORMANCE TESTING Index
The following test shall be conducted by the installer or representative prior to those tests listed in 4-5.1.3, "System Verification." Test gas shall be oil-free dry nitrogen. (ANSI/NFPA 99 4-5.1.2)
2. PRESSURE TEST (INITIAL) Index
Before attachment of system components (e.g .,pressure-actuating switches for alarms, manifolds, pressure gauges, or pressure relief valves), but after installation of the station outlets, with test caps (if supplied) in place (e.g., rough-assembly), and before closing of the walls, each section of the piping system shall be subjected to a test pressure of 1.5 times the working pressure [minimum 150 psig (1 MPa gauge)] with oil-free dry nitrogen. Test pressure shall be maintained until each joint has been examined for leakage by means of soapy water or other equally effective means of leak detection safe for use with oxygen. The source shutoff valve shall be closed. Leaks, if any, shall be located, repaired, and retested in accordance with this paragraph. (ANSI/NFPA 99 4-184.108.40.206)
3. BLOWDOWN TEST Index
After installation of the piping, but before installation of the station outlets and other medical gas system components (e.g., pressure-actuating switches for alarms, manifolds, pressure gauges, or pressure relief valves), the line shall be blown clear by means of oil-free dry nitrogen. (ANSI/NFPA 99 4-220.127.116.11)
4. PRESSURE TEST Index
After testing of each individual medical gas system, the completely assembled station outlets and all other medical gas system components (e.g., pressure-actuating switches for alarms, manifolds, pressure gauges, or pressure relief valves) shall be installed, and all piping systems shall be subjected to a 24-hour standing pressure test at 20 percent above the normal operating line pressure. The test gas shall be oil-free, dry nitrogen. The source shutoff valve shall be closed. (ANSI/NFPA 4-18.104.22.168)
(a) After the piping system is filled with test gas, the supply valve and all outlets shall be closed and the source of test gas disconnected. The piping system shall remain leak-free for 24 hours. When making the standing pressure test, the only allowable pressure changes during the 24-hour test period shall be those caused by variations in the ambient pressure-temperature relationship: the calculated final absolute pressure (absolute pressure is gauge pressure plus 14.7 psig if gauge is calibrated in psig) equals the initial absolute pressure times the final absolute temperature (absolute temperature is temperature reading plus 460 degrees F if the thermometer is calibrated in Fahrenheit degrees), divided by the initial absolute temperature.
[Pf = Pi (x) Tf]
(b) Leaks, if any, shall be located, repaired, and retested.
5. PIPING PURGE Index
In order to remove particulate matter in the pipelines, a heavy, intermittent purging of the pipeline shall be done. The appropriate adapter shall be obtained, and a high-flow purge shall be put on each outlet. The outlet shall be allowed to flow fully until the purge produces no discoloration in a white cloth. (ANSI/NFPA 99 4-22.214.171.124)
6. CROSS-CONNECTION TEST Index
(a) Prior to closing walls, it shall be determined that no cross-connection of piping systems exists. All medical gas Systems shall be reduced to atmospheric pressure. All sources of test gas shall be disconnected from all of the medical gas systems with the exception of the one system to be checked. This system shall be pressurized with oil-free nitrogen to 50 psig (350 kpa gauge). With appropriate adapters matching outlet labels, each individual station outlet of all medical gas systems installed shall be checked to determine that test gas is being dispensed only from the outlets of the medical gas system being tested. (ANSI/NFPA 4-126.96.36.199(a))
|(1) The source of test gas shall be disconnected and the system tested shall be reduced to atmospheric pressure. Proceed to test each additional piping system in accordance with 4-188.8.131.52(a).
(2) Where a medical vacuum piping system is installed, the cross-connection testing shall include that piped vacuum system with all medical gas piping systems.
(3) All medical-surgical vacuum systems shall be in operation so that these vacuum systems are tested at the same time the medical gas systems are tested.
(4) Each station outlet shall be identified by label (and color marking, if used).
(b) The presence and correctness of labeling required by this standard for all components (e.g., station outlets, shutoff valves, and signal panels) shall be verified. (ANSI/NFPA 99 4-184.108.40.206(b))
7. SYSTEM VERIFICATION Index
The following test shall be performed after those listed in 4-5.1.2, "Installer Performance Testing." The test gas shall be oil-free, dry nitrogen.
This testing shall be conducted by a party technically competent and experienced in the field of medical gas pipeline testing. (ANSI/NFPA 99 4-5.1.3)
8. CROSS-CONNECTION TEST AFTER CLOSING WALLS Index
(a) After closing of walls and completion of requirements of 4-5.1.2, it shall be determined that no crossconnection of piping systems exists. All medical gas systems shall be reduced to atmospheric pressure. All sources of test gas from all of the medical gas systems, with the exception of the one system checked, shall be disconnected. This system shall be pressurized with oil-free nitrogen to 50 psig (350 kpa gauge). With appropriate adapters matching outlet labels, each individual station outlet of all medical gas systems installed shall be checked to determine that test gas is being dispensed only from the outlets of the medical gas system being tested. (ANSI/NFPA 99 4-220.127.116.11)
|(1) The source of test gas shall be disconnected and the system tested reduced to atmospheric pressure. Proceed to test each additional piping system in accordance with 4-18.104.22.168(a).
(2) Where a medical vacuum piping system is installed, the cross-connection testing shall include that piped vacuum system with all medical gas piping systems.
(3) An alternate method of testing to ensure that no cross-connection to other piping systems exists follows:
|(i) Reduce the pressure in all medical gas Systems to atmospheric.
(ii) Increase the test gas pressure in all medical gas piping systems to the values indicated in Table 4-22.214.171.124(a)(3). Simultaneously maintain these nominal pressures throughout the test.
(iii) Any medical-surgical vacuum systems shall be in operation so that these vacuum systems are tested at the same time the medical gas systems are tested. (ANSI/NFPA 4-126.96.36.199)
TABLE 4-188.8.131.52(a)(3) ALTERNATE TEST PRESSURES
NOTE: Systems at nonstandard pressures shall be tested at a pressure at least 10 psi (69 kpa) greater or less than any other system.
|(iv) Following the adjustment of pressures in accordance with 4-184.108.40.206 (a)(3)(ii), each station outlet for each medical gas system shall be tested using the gas-specific connection for each system with a pressure (vacuum) gauge attached. Each pressure gauge used in performing this test shall be calibrated with the line pressure regulator gauge used to provide the source pressure.
(v) Each station outlet shall be identified by label (and color marking, if used), and the pressure indicated on the test gauge shall be that listed in 4-220.127.116.11 (a)(3)(ii) for the system being tested.
(b) The presence and correctness of labeling required by this standard for all components (e.g., station outlets, shutoff valves, and signal panels) shall be verified.
9. VALVE TEST Index
Valves installed in each medical gas piping system shall be tested to verify proper operation and rooms or areas controlled by each valve for each gas. The information shall be utilized to assist and verify the proper labeling of the valves.
10. FLOW TEST Index
(a) All outlets shall be tested for flow. Test shall be performed with the use of oil-free, dry nitrogen as described in CGA P-9, Inert Gases: Argon, Nitrogen and Helium.
(b) Oxygen, nitrous oxide, and air outlets shall deliver 3.5 CFM with a pressure drop of no more than 5 psig (35 kpa), and static pressure of 50 psig (349 kPa).
(c) Nitrogen outlets shall deliver 5.0 SCFM with a pressure drop of no more than 5 psig and static pressure of 160 psig (1118 kPa). (ANSI/NFPA 99 4-18.104.22.168)
11. ALARM TESTING Index
(a) All warning systems for each medical gas piping system shall be tested to ensure that all components function properly prior to placing the piping system in service. Permanent records of these tests shall be maintained. Warning systems that are part of an addition to an existing piping system shall be tested prior to the connection of the new piping to the existing system.
(b) Warning Systems
Tests of warning systems for new installations (initial tests) shall be performed after the cross-connection testing ), but before the purging and verifying (4-22.214.171.124). Initial tests of warning systems that may be included in an addition or extension to an existing piping shall be completed before connection of the addition to the existing system. Test gases for the initial test shall be oil-free, dry nitrogen.
(c) Master Alarm Systems
|(1) The master alarm system tests shall be performed for each of the nonflammable medical gas piping systems. Permanent records of these tests shall be maintained with those required under 4-6-3.1
(2) The audible and noncancellable visual signals of 4-126.96.36.199(f) shall indicate if the pressure in the main line increases or decreases 20 percent from the normal operating pressure.
(d) Area Alarm Systems
The warning signals for all medical gas piping systems supplying anesthetizing locations and other vital life-support and critical care areas, such as postanesthesia recovery, intensive care units, coronary care units, etc., shall indicate if the pressure in the piping system increases or decreases 20 percent from the normal operating pressure. [See 4-188.8.131.52(a).] (ANSI/NFPA 99 4-184.108.40.206)
12. PIPING PURGE TEST Index
In order to remove any traces of particulate matter deposited in the pipelines as a result of construction, a heavy intermittent purging of the pipeline shall be done. The appropriate adapter shall be obtained from the facility or manufacturer, and high purge rates of at least 225 L per mm. (8 cfm) shall be put on each outlet. After the purge is started, it shall be rapidly interrupted several times until the purge produces no discoloration in a white cloth loosely held over the adapter during the purge. In order to avoid possible damage to the outlet and its components, this test shall not be conducted using any implement other than the proper adapter.
For each positive-pressure gas system, cleanliness of piping system shall be verified. Filter a minimum of 35 cu ft (l000 L) of gas through a clean white, 0.45-micron filter at a minimum of 3.5 SCFM (100 Lpm) Filter shall show no discoloration, and shall accrue no more than 0.1 mg of matter. Each zone shall be tested at the outlet most remote from the source. Test shall be performed with the use of oil-free, dry nitrogen. (ANSI/NFPA 4-220.127.116.11)
13. PIPING PURITY TEST Index
For each positive-pressure system , the purity of the piping system shall be verified. Test each zone at the most remote outlet for dew point, total hydrocarbons (as methane), and halogenated hydrocarbons, and compare with source gas. The two tests shall in no case exceed variation as specified in the Maximum Allowable Variation Table, which follows. Test shall be performed with the use of oil-free nitrogen gas. (ANSI/NFPA 99 5-18.104.22.168)
Maximum Allowable Variation Table
|Total Hydrocarbons as Methane
||+ 1 ppm
||+ 2 ppm
14. FINAL TIE-IN TEST Index
Prior to the connection of any work or any extension or addition to an existing piping system, the tests in 4-22.214.171.124 through 4-126.96.36.199 shall be successfully performed. After connection to the existing system and before use of the addition for patient care, the tests in 4-188.8.131.52 through 4-184.108.40.206 shall be completed. Permanent records of these tests shall be maintained in accordance with 4-6.3.1
The final connection between addition and existing system shall be leak-tested with the gas of system designation at the normal operating pressure. This pressure shall be maintained until each joint has been examined for leakage by means of soapy water or other equally effective means of leak detection safe for use with oxygen. (ANSI/NFPA 99 4-220.127.116.11)
15. OPERATIONAL PRESSURE TEST Index
(a) Piping systems, with the exception of nitrogen systems, shall maintain pressure at 50 + 5/-0 psig (345 + 35/-0 kpa gauge) at all station outlets at the maximum flow rate in 4-18.104.22.168(d) and (e).
(b) A nitrogen system shall be capable of delivering at least 160 psig (1100 kpa gauge) to all outlets at flow in 4-22.214.171.124(e).
(c) Piping systems that vary from the normal pressures in 4-126.96.36.199(a) and (b) shall be capable of delivering flows and pressures consistent with their intended use.
(d) Oxygen, nitrous oxide, and air outlets shall deliver 3.5 SCFM with a pressure drop of no more than 5 psig (35 kpa) and static pressure of 50 psig (350 kPa).
(e) Nitrogen outlets shall deliver 5.0 SCFM with a pressure drop of no more than 5 psig (35 kpa) and static pressure of 160 psig (1118 kpa). (ANSI/NFPA 4-188.8.131.52)
16. MEDICAL GASES CONCENTRATION TEST Index
After purging each system with the gas of system designation, the following shall be performed:
(a) Each pressure gas source and outlet shall be analyzed for concentration of gas, by volume.
(b) Analysis shall be with instruments designed to measure the specific gas dispensed.
(c) Allowable concentrations shall be within the following:
||99 plus percent oxygen
||99 plus percent nitrous oxide
||Less than 1 percent oxygen or 99 plus percent nitrogen
||19.5 percent to 23.5 percent oxygen
||Concentrations to 23.5 percent oxygen labeling plus or minus 1 percent, unless otherwise specified
17. MEDICAL AIR PURITY TEST (COMPRESSOR) Index
Analyze medical air source for concentration of contaminants, by volume. Take samples for air system
test at a sample point. The compared tests shall in no case exceed variation as specifed under the
Maximum Allowable Variation Table (4-184.108.40.206). Allowable concentrations shall be as follows:
(ANSI/NFPA 99 4-220.127.116.11)
|| + 390 F (40C) @ 50psig
|Carbon Dioxide - Air
|Gaseous Hydrocarbons - Air
||< 25ppm (as methane)
|Halogenated Hydrocarbons - Air
18. SOURCE EQUIPMENT VERIFICATION Index
This testing shall be conducted by a party technically competent and experienced in the field of medical gas pipeline testing. (ANSI/NFPA 99 4-5.1.4)
TABLE 4-5.1.4 REQUIRED MASTER ALARM SIGNALS
||Reserve In Use
||Dew Point High
|Manifolds with Reserve
|Cyrogenic Bulk Gas Units (VIE) with Cyrogenic Reserve
|Cyrogenic Bulk Gas Units (VIE) with Cylinder Reserve
|Note A: This signal is required only where cylinder reserves have no check valves for each cylinder lead.
||High Pressure or Vacuum
||Low Pressure or Vacuum
|All Pressure Gas Systems
19. GAS SUPPLY SOURCES (ANSI/NFPA 99 4-18.104.22.168) Index
(a) The system apparatus shall be tested for proper function, including changover from one cylinder bank to the other and the actuation of the changeover signal, before the system is put into service.
(b) The system apparatus shall be tested for proper function, including the changeover from primary to secondary supply (with its changeover signal) and the operation of the reserve (with its reserve in use signal), before the system is put into service.
(c) If the system has an actuating switch and signal to monitor the contents of the reserve, its function shall be tested before the system is put into service.
(d) The bulk supply signal and the master signal panel installations shall be arranged with the owner or the organization responsible for the operation and maintenance of the supply system for the testing of the bulk supply signals to ensure proper identification and activation of the master signal panels to be sure the facility can monitor the status of that supply system. These tests shall also be conducted when changing storage units.
(e) For master alarm systems, the manufacturer's operating instructions shall be followed, or the assistance of the owner or the organization responsible for the operation and maintenance of the bulk supply system shall be requested for the following tests.
|(1) Pressurize the piping system and connect the electric power to the signal panels.
(2) Check the main-line pressure gauges [see 4-22.214.171.124(a)] to ascertain that it indicates the desired pressure [see 4-126.96.36.199) and is properly labeled. Check the alarm signal panels to ensure that they indicate normal operation and that none of the warning signals are activated.
20. MEDICAL AIR COMPRESSOR (ANSI/NFPA 99 4-188.8.131.52) Index
(a) The proper flinctioning of the medical compressed air system shall be tested before it is put into service. This shall include the purity test for air quality, and the test of the alarm sensors after calibration and setup per the manufacturer's instructions and automatic switchover as outlined in 4-184.108.40.206.
(b) The following tests shall be conducted at the sample point of the medical air system.
|(1) The operation of the system control sensors, such as dew point, air temperature, and all other air-quality monitoring sensors and controls, shall be checked for proper operation and flinction before the system is put into service.
(2) The quality of medical compressed air as delivered by the compressor air supply shall be verified upon installation and after 24 hours of operation at a sample point downstream of the pressure regulator and upstream of the piping system.
21. GAS SYSTEM TEST (PRESSURE, VALVES, ETC.) Index
(1) The medical gas system, including cylinders and pressure regulators, shall deliver gas at a pressure per 4-220.127.116.11. (ANSI/NFPA 99 4-18.104.22.168)
(2) Flexible connectors of other than all-metal construction used to connect outlets of pressure regulators to fixed piping shall have a minimum burst pressure of 1000 psig (7000 kPa gauge). (See 4-4.2.4) (ANSI/NFPA 99 4-22.214.171.124)
(3) The pressure relief valve specified in 4-4.2.6 shall close automatically when excess pressure has been released (ANSI/NFPA 99 4-126.96.36.199)
22. ALARM TESTING FOR GAS SYSTEMS Index
The automatic pressure switch connected to each main supply line within a single treatment facility shall actuate a visual and audible alarm when the line pressure drops approximately 20 percent below or increases approximately 20 percent above normal line pressure. (See 4-4.2.9) (ANSI/NFPA 99 4-5.2.4)
23. INSTALLATION AND TESTING OF GAS PIPING SYSTEMS Index
The provisions of 4-5.1.2 (Installer Performance Testing ) and 4-5.1.3 (System Verification) shall apply.
24. ADMINISTRATION OF GAS SYSTEMS Index
Patient Gas Systems - Type I
1. The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to establish the proper function of the medical gas system. (ANSI/NFPA 99 4-188.8.131.52)
2. Complete Loss of Any Medical Gas System. The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system. (ANSI/NFPA 99 4-184.108.40.206)
3. A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented. (ANSI/NFPA 99 4-220.127.116.11)
4. The test specified in 4-18.104.22.168 shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed. (ANSI/NFPA 99 4-22.214.171.124)
5. Periodic testing of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test. (ANSI/NFPA 99 4-126.96.36.199)
25. RECORDKEEPING FOR GAS SYSTEMS Index
Patient Gas Systems - Type I
1. The gas content and operating pressure of medical gas piping systems shall be readily identifiable by appropriate labeling with the name and pressure of the gas contained. Such labeling shall be by means of metal tags stenciling, stamping, or adhesive markers, in a manner that is not readily removable. Labeling shall appear on the piping at intervals of not more than 20 ft (6 m) and at least once in each room and each story traversed by the piping system. Where supplementary color identification of piping is used, it shall be in accordance with the gases and colors indicated in CGA Phamplet C9 "Standard Color Marking of Compressed Gas Cylinders Intended for Medical Use." (ANSI/NFPA 99 4-6-4.1.1)
2. The shutoff valves shall be labeled as follows:
(ANSI/NFPA 99 4-188.8.131.52)
|CAUTION - (NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO...
3. Pressure gauges and manometers for medical gas piping systems shall be identified: (NAME OF GAS) USE NO OIL! (ANSI/NFPA 99 4-184.108.40.206)
Patient Gas Svstems - Type II
The shutoff valve shall be labeled to indicate the gas controlled and to indicate that they are to be closed only in an emergency. (ANSI/NFPA 99 4-6.4.2)
26. NUMBER OF VACUUM STATION INLETS Index
Table 4-7.1.2 sets forth the minimum number of vacuum system station inlets for patient suction therapy, but does not include station inlets for disposing of waste anesthetic gases. (ANSI-NFPA 99 4-7.1.2)
TABLE 4-7.1.2 MINIMUM NUMBER OF VACUUM STATION INLETS
(WITHOUT WASTE ANESTHETIC GAS DISPOSAL)
Note: If it is intended to use the vacuum system for waste anesthetic gas disposal, provision for an additional inlet should be made.
|Other Anesthetizing Locations
|Acute Care Locations (Non-anesthetizing Locations)
|Intensive Care Units (Except Cardiac)
|Emergency Rooms - Major Trauma
|Cardiac Intensive Care Units
|Surgical Excision Rooms
|Subacute Patient Care Areas (Nonanesthetizing Locations
|Exam and Treatment Rooms
|Equipment Repair, Calibration, and Teaching
27. MEDICAL-SURGICAL VACUUM PUMPS (ANSI/NFPA 99 4-8.1.1) Index
1. Multiple Pumps. The central vacuum source shall consist of two or more vacuum pumps that, alternately or simultaneously on demand, serve the vacuum system. Each vacuum system shall be served by two or more vacuum pumps that, alternately or simultaneously on demand, supply the vacuum system. In the event that ( vacuum pump fails, the remaining pump(s) shall be sized to maintain required vacuum at 100 percent of total system demand. Each pump shall have a shutoff valve to isolate it from the centrally piped system and other pump(s) for maintenance or repair without loss of vacuum in the piping system.
2. Pump Alternation. If automatic alternation of pumps in normal service is not provided, a manual alternation shall be achieved through an appropriate schedule determined by the facility.
3. Backup Operation. A device shall be provided to automatically activate the additional pump unit(s) if the pump in operation is incapable of maintaining minimum required vacuum.
4. Exhausts. The exhaust from vacuum pumps shall be discharged outdoors in a manner that will minimize the hazards of noise and contamination to the hospital and its environment. The exhaust shall be located remote from any door, window, air intake, or other openings in buildings with particular attention given to separate levels for intake and discharge. Care shall also be exercised to avoid discharge locations contra-indicated by prevailing winds, adjacent buildings, topography, and other influences. Outdoor exhausts shall be protected against the entry of insects, vermin, debris, and precipitation. Exhaust lines shall be sized to minimize back pressure. Discharge of pumps utilizing common exhaust pipe shall be fitted with a check valve, a manual valve, or arranged to permit capping of the active pipe when removing or servicing a pump.
NOTE: Vacuum exhaust from separate pumps may be manifolded to a common exhaust line.
28. WASTE ANESTHETIC GAS DISPOSAL Index
Where pumps are used in a dedicated vacuum system used for the disposal of anesthetic gases, these pumps shall conform to the requirements of 4-220.127.116.11. (ANSI/NFPA 99 4-8.1.2)
NOTE: Nonflammable waste anesthetic gases may be disposed of by the medical-surgical vacuum system provided that its inclusion does not affect the performance of other parts of the system as outlined in 4-18.104.22.168 and in 4-22.214.171.124
29. EXPLOSION HAZARD Index
Flammable anesthetic or other flammable vapors shall be diluted below the lower flammable limit prior to disposal irno the medical-surgical vacuum system. (ANSI/NFPA 99 4-126.96.36.199)
NOTE: Flammable and nonflammable gases are known to be incompatible with some seals and piping used in medical-surgical vacuum systems. If waste anesthetic gas disposal is to be included as part of the medical surgical vacuum system, it should be recognized that this activity may cause deterioration of the vacuum system. The station inlet performance tests outlined in 4-188.8.131.52 are extremely important in maintaining the integrity of the medical-surgical vacuum system, and they should be made at more frequent intervals if waste anesthetic gas disposal is included in the vacuum system.
30. PUMPS FOR WASTE ANESTHETIC GAS DISPOSAL Index
Pumps of dedicated waste anesthetic gas disposal systems shall be water sealed or have inert materials in the compression chamber. (ANSI/NFPA 99 4-184.108.40.206)
31. LABORATORY VACUUM Index
Where only one set of vacuum pumps is available for a combined medical-surgical vacuum system and an analysis, research, or teaching laboratory vacuum system, such laboratories shall be connected separate from the medical-surgical system directly to the receiver tank through its own isolation valve and fluid trap located at the receiver. Between the isolation valve and fluid trap, a scrubber shall be permitted to be installed. (ANSI/NFPA 99 4-8.2.1)
NOTE: Any laboratory (such as for analysis, research, or teaching) in a hospital that is used for purposes other than direct support of patient therapy should preferably have its own self-supporting vacuum system, independent of the medical-surgical vacuum system. A small laboratory in patient care areas used in direct support of patient therapy should not be required to be connected directly to the receiver or have fluid traps, scrubbers, etc., separate from the rest of the medical-surgical vacuum system.
32. VACUUM SYSTEM VALVE BOXES Index
Valve boxes shall be permanently label in substance as follows:
(ANSI/NFPA 99 4-220.127.116.11)
MEDICAL-SURGICAL VACUUM VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS VACUUM TO....
33. VACUUM SYSTEM VALVES NOT IN BOXES Index
All shutoff valves that are not in labeled boxes, such as in the main line, risers, or above suspended ceilings, shall be identified by means of durable tags, nameplates, or labels in substance as follows:
(ANSI/NFPA 99 4-18.104.22.168)
MEDICAL-SURGICAL VACUUM VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS VACUUM TO...
34. VACUUM SYSTEM STATION INLETS Index
Each station inlet for vacuum shall be legibly labeled in substance as follows:
(ANSI/NFPA 99 4-22.214.171.124)
or, if used,
|WASTE ANESTHETIC GAS DISPOSAL
35. VACUUM SYSTEM SHUTOFF VALVES (ANSI/NFPA 99 4-126.96.36.199) Index
(a) General. Shutoff valves shall be provided to isolate appropriate sections or portions of the piping system for maintenance, repair, or planned future expansion need, and to facilitate periodic testing. All valves, other than those in valve boxes, shall be placed in a secure area accessible to authorized personnel only or locked open.
(b) Valve Types. Shutoff valves shall be metallic and of a type that will create no greater flow restriction than the piping to which they are connected.
(c) Riser Valves. Shutoff valves shall be provided at the base of vertical risers servicing more than one floor.
(d) Section Valves. A shutoff valve shall be provided on each floor between the riser and the first station inlet to allow for maintenance and periodic testing without serious disruption of service. In single-story facilities a shutoff valve shall be installed between the main line and the first terminal of each branch line.
(e) Valve Boxes. All shutoff valves in public and anesthetizing areas shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of the valve.
NOTE: Shutoff valves are not required for each anesthetizing room.
36. VACUUM SYSTEM STATION INLETS (ANSI/NFPA 99 4-188.8.131.52) Index
(a) General. Each station inlet for vacuum shall be equipped with a valve mechanism of a type not interchangeable with other systems (e.g., oxygen, compressed air) and either a threaded connection or a quick coupler.
(b) Threaded Connections. Valves with threaded connections shall conform to Diameter-Index Safety System. (CGA Phamplet V-5)
(c) Secondary Check Valves. Vacuum station inlets shall not incorporate a secondary check valve.
(d) Physical Protection. Station inlets shall be located so as to avoid physical damage to the valve or attached equipment.
(e) Physical Spacing. Careful consideration shall be given to provide adequate spacing between the station inlets and adjacent medical gas outlets.
(f) Removable Assemblies. Station inlet assemblies, as furnished by manufacturers, shall be legibly marked VACUUM or SUCTION so that, in their state of disassembly for hookup to the vacuum system, proper identification is not lost.
37. MASTER ALARM SYSTEM FOR VACUUM SYSTEMS (ANSI/NFPA 99 4-184.108.40.206) Index
(a) General. The vacuum system master alarm shall provide cancellable audible and noncancellable visual signals at a continuously monitored location so as to indicate when the vacuum in the main line drops below the level required in 4-10.1.2.1. When one continuously monitored location is not available, a secondary master alarm shall be installed at some location, such as the telephone switchboard or the security office, where it is most likely to be seen or heard.
(b) Actuator Switch. The actuator (vacuum switch) for the master alarm shall be connected to the main line immediately upstream (on the terminal or inlet side) of the main-line valve [i.e., the main-line valve is between the receiver (tank) and the master alarm vacuum switch].
(c) Alarm Panels. The master alarm signal panel(s) required in 4-220.127.116.11(a) (each with visual and audible signal) shall be actuated by the vacuum switch described in 4-18.104.22.168(b).
(d) Panel Labels. The master alarm signal panel(s) shall be appropriately labeled.
(e) Combined Alarm Signals. The vacuum alarm signal shall serve only the medical-surgical vacuum system.
|NOTE: The master alarm signal panel for the vacuum system may be combined with other alarm signals for other facility systems, such as oxygen, emergency electrical power, or fire alarms, provided that the function of this alarm signal is clearly distinguished from the others by labeling.
(f) Alarm System Power. The master alarm signal system shall be energized by the essential electrical system.
(g) Connection to Centralized Computers. The connection of the master alarm(s) to a centralized computer (e.g., a building management system) shall be permitted. If computers are used as a secondary master alarm, the requirement of 4-22.214.171.124(e) and (f) shall be met. The primary master alarm shall be a separate device.
38. AREA ALARM SYSTEMS FOR VACUUM SYSTEMS (ANSI/NFPA 99 4-126.96.36.199) Index
(a) General. Vacuum area alarm systems shall be provided in anesthetizing location areas and other life-support and critical care areas, such as postanesthesia recovery, intensive care units, or coronary care units.
(b) Visual and Audible Alarms. The vacuum area alarm system shall incorporate both cancellable audible and noncancellable visual signals that are activated by actuators (vacuum switches) connected to the vacuum line serving each specific area.
(c) Alarm Panels. The visual and audible signal panels shall be installed at nurses' stations or other suitable locations in the areas described in 4-188.8.131.52(a) and be appropriately labeled.
(d) Actuator Switches. The actuator (vacuum switch) for each area described in 4-184.108.40.206(a) shall connect the vacuum line for that area and upstream (on the terminal or inlet side) of any shutoff valves, with no shutoff valves intervening between the area alarm actuator (vacuum switch) and the station inlets in the area.
(e) Actuator Switch Settings. Actuators (vacuum switches) for the area alarm signals shall be set to activate their respective warning signals (visual and audible) when the vacuum drops below 12 in. HG (vacuum).
(f) Electrical Power. The area alarm signal system shall be energized by the essential electrical system.
39. VACUUM SYSTEM GAUGES (ANSI/NFPA 99 4-220.127.116.11) Index
(a) Main-Line Gauge. A vacuum gauge shall be provided in the main vacuum line adjacent to the actuator (vacuum switch) for the master alarm, with this gauge located immediately upstream (on the terminal or inlet side) of the main-line valve. Those with "normal range" display shall indicate normal only between 12 and 19 in. Hg (vacuum).
(b) Area Gauge. Vacuum gauges shall be located at each area vacuum alarm signal location, with this gauge connected upstream (on the terminal side or inlet side) of any valve controlling that area. Those with "normal range" display shall indicate normal only between 12 and 19 in. Hg (vacuum).
(c) Vacuum Gauge Identification. All permanently installed vacuum gauges and manometers for the vacuum system shall be continous reading, manufactured expressly for vacuum, and labeled: VACUUM.
|NOTE 1: Vacuum gauges should have an indicated range of 0 in. to 30 in. Hg (vacuum).
NOTE 2: Vacuum gauges may be part of shutoff valves in boxes, or incorporated in a unit with gauges for the central medical gas piping systems.
40. WASTE ANESTHETIC GAS DISPOSAL Index
Waste anesthetic gas evacuation terminals, whose vacuum source is separate from the medical-surgical vacuum source, shall be equipped with a valve mechanism of a type not interchangeable with the medical-surgical vacuum system or with other systems. (ANSI/NFPA 99 4-9.1.2)
41. MINIMUM VACUUM AND OPERATING RANGE Index
The vacuum pumps and collection piping shall be capable of maintaining a vacuum of 12 in. of mercury (Hg) at the station inlet farthest away from the central vacuum source when the calculated demand for the hospital is drawn in the system. (ANSI/NFPA 99 4-18.104.22.168)
42. OVERALL SYSTEM PRESSURE-DROP CRITERIA Index
Tube sizes shall be in conformity with good engineering practice for delivery of maximum design volumes. (ANSI/NFPA 99 4-10.1.1.2)
|NOTE: It is recommended that vacuum pressure loss, from source to farthest station inlet when the calculated demand is drawn on the vacuum system, be limited to 3 in. Hg.
43. MINIMUM FLOW AND PRESSURE REQUIREMENTS AT VACUUM STATION INLETS Index
Piping shall be sized such that 3 SCFM can be evacuated through any one station inlet without reducing vacuum pressure below 12 in. Hg at an adjacent station inlet. (ANSI/NFPA 99 4-10.1.1.3)
44. TESTING Index
The following tests shall be conducted to ensure proper operation of the system upon completion of the installation, and before turnover to the facility for patient use. (ANSI/NFPA 99 4-10.1.2)
45. INSPECTION OF VACUUM SYSTEMS Index
A visual inspection of each soldered or brazed joint, if any, shall be made to ensure that the alloy has flowed completely in and around the joint and that hardened flux has not formed a temporary seal that holds test pressure. All excess flux shall be removed for clear visual inspection of connections. (ANSI/NFPA 99 4-10.1.2.1)
46. LEAKAGE TESTS Index
Before attaching the vacuum lines to the vacuum pumps, receiver(s) [tanks(s)], and alarm signaling system(s) switches and gauges, each section of the vacuum piping system shall be subjected to a test pressure not less than 150 psig (1034 kpa gauge) by means of oil-free, dry nitrogen or air. This test pressure shall be maintained until each joint has been examined for leakage by use of soapy water or other suitable means. All leaks shall be repaired and the section retested. (ANSI/NFPA 99 4-10.1.2.2)
The facility shall perform periodic tests for detecting leaks in the system. (ANSI/NFPA 99 4-22.214.171.124)
47. STANDING PRESSURE TEST Index
After installing a vacuum system, including station inlets, but before attaching the vacuum lines to the vacuum pumps, receiver(s) [tank(s)], and alarm system(s) switches and gauges, the entire system or sections of the system shall be subjected to a test pressure of not less than 60 psig (413 kPa gauge) by means of oil-free, dry nitrogen or air. After allowance for temperature variation, the pressure at the end of 24 hours shall be within 5 psig (345 kpa gauge) of the initial pressure. Corrective action shall be taken if this performance is not verified. After completion of the test, corrections, and reverification if necessary, the system shall be connected to the vacuum pumps, receiver(s) [tank(s)], alarm actuators (vacuum switches), and gauges. (ANSI/NFPA 99 4-10.1.2.3)
48. VACUUM TEST Index
After connecting the vacuum piping to the vacuum pumps, receiver(s) [tank(s)], vacuum gauges, and vacuum alarm switches, a vacuum test shall be performed on the entire system. (ANSI/NFPA 99 4-10.1.2.5)
NOTE: An acceptable method of testing is by means of shutting down portions of the system using the shutoff valves to determine the capability of that portion to maintain a vacuum. An acceptable condition is a vacuum level loss of less than 1.5 Hg in 1 hour with the vacuum system piping initially at a vacuum in excess of 12 in Hg.
49. VACUUM SYSTEM ALARM TESTING Index
The vacuum system master alarm and any secondary master alarm shall signal when the vacuum in the main line drops below the level required to maintain 12 in Hg (vacuum) at the station inlet farthest from the source. (ANSI/NFPA 99 4-10.1.2.6)
50. MAINTENANCE Index
The facility shall establish preventive maintenance programs applicable to both the vacuum piping system and to the secondary equipment attached to vacuum station inlets to ensure the continued good performance of the entire vacuum system. (ANSI/NFPA 99 4-126.96.36.199.1)
51. STATION INLET PERFORMANCE TESTS Index
Station inlet terminal performance, as required in 4-10.1.1.3, shall be tested on a regular preventive maintenance schedule as determined by the facility maintenance staff. The test shall be based on flow of free air (SCFM) into a station inlet while simultaneously checking the vacuum level. (ANSI/NFPA 99 4-188.8.131.52)
The test can be conducted using (1) a rotometer or other flow-measuring device and (2) a vacuum gauge, both devices being fitted with the appropriate station inlet connector. The test procedure will be to measure the flow with the station inlet wide open while simultaneously measuring the vacuum level at an adjacent wall station inlet or other station inlet on the same branch line. It is recognized that this criterion may not be met by some existing systems. It is the responsibility of facility personnel, based on past experience and use, to determine the acceptable alternate performance criterion for their system(s).
52. INSTRUCTION OF STAFF Index
The facility shall instruct its personnel in the proper use of the vacuum system in order to eliminate practices that reduce the system's effectiveness, such as leaving suction tips and catheters open when not actually aspirating, and using equipment arrangements that are improperly trapped or are untrapped. (ANSI/NFPA 99 4-184.108.40.206)
|NOTE: Suction collection bottles that are used as part of patient treatment equipment should be equipped with an overflow shutoff device to prevent carryover of fluids into equipment of the piping system. It is recommended that a separate vacuum trap with shutoff be used between the suction collection bottle and the vacuum system station inlet.
53. CONTAMINATION Index
Liquid or debris shall not be introduced into the medical-surgical vacuum system for disposal. (ANSI/NFPA 99 4-220.127.116.11)
54. NON-MEDICAL USE Index
The medical-surgical vacuum system shall not be used for vacuum steam condensate return or other non-medical or nonsurgical applications. (ANSI/NFPA 99 4-18.104.22.168)
55. MODIFICATIONS Index
Whenever the medical-surgical vacuum system is breached, the tests of Section 4-10 shall be conducted on any new or modified portion of the system. (ANSI/NFPA 99 4-22.214.171.124)
56. RECORDKEEPING FOR VACUUM SYSTEMS Index
Upon completion of the tests described in 4-10.1, a written record of the performance of these test shall be maintained in the permanent records of the facility. (ANSI/NFPA 99 4-11.3)