Medical Gas Shutoff Valves

Q: As a hospital security assessor, I am concerned about the availability of hospital gases in Behavioral Health Units. It would be easy for a patient to pull the tab off the plastic covering on the window and tamper with the gases. Would it be permissible to install a clear locking door with hardened glass in place of the plastic panel and provide access to the locked box via scan card with the caveat that the door would automatically unlock open during a fire event?

A: One has to ask why would there be medical gases on a behavioral health unit? Do you treat acute-care patients there? However, if you have them there, then you need to deal with them.

Your question appears to address the medical gas shutoff valves, or zone valves as they are often called. According to NFPA 99-2012, section, zone valves have to be visible, accessible and readily operable from a standing position in the corridor. NFPA 99-2012 does not prohibit the use of special locking arrangements for access to the zone valves.

I think you have a legitimate concern, especially if you document this concern in a risk assessment. But I suggest you contact your authorities having jurisdiction, and ask them if it would be permitted. At a minimum, I suggest you ask:

  • Your accreditation organization
  • Your state agency in charge of hospital design and construction
  • Your local building authorities
  • Your state or local fire marshal

Outdoor Storage of O2 Cylinders

Q: We had a finding from a recent Joint Commission survey on EC. 02.01.01, EP 3. When the surveyor told us about it, he said it related back to an NFPA standard, but he didn’t say which one. What he cited us for was not having a roof over our empty O2 storage tanks that are kept out on the back dock. They are in a caged area, and are in racks. Do you know what NFPA standard we should look up to figure out how to correct this?

A: EC.02.01.01, EP 3 is a general-duty type of standard where TJC can cite anything that they feel is an un-safe condition. It is frequently used interchangeably  with EC.02.06.01, EP 1. I suspect the surveyor used EC.02.01.01, EP 3 in this case because the deficiency was observed outside the building, and EC.02.06.01, EP 1 is for interior spaces.

So… the finding was the empty O2 cylinders did not have a roof over them, even though they were properly secured. I have reviewed NFPA 99, 1999 edition and cannot find a specific reference where O2 cylinders stored outside need to have a roof over them. Section 8- of NFPA 99-1999 says storage locations of nonflammable gases must be either outdoors in an enclosure or within an enclosed interior space of non-combustible construction. The definition of ‘enclosure’ does not include a reference to a roof.

However, section 4- says “Sources of heat in storage locations shall be protected or located so that cylinders of compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130⁰F.” So, are O2 cylinders (even empty cylinders) that are exposed to the sunlight capable of exceeding 130⁰F and would their integral safety devices be activated? Apparently the surveyor thought so. If you disagree, you can appeal this finding through the clarification process and try to get it removed but I suspect the clarification would not be accepted.

Just my two cents worth… I’ve always seen roofs over outdoor O2 cylinder storage locations wherever I go.


Door to Medical Gas Storage Room

Q: I have an existing medical gas storage room in an outpatient surgery center that was constructed with 1-hour barriers and ¾ hour fire rated door. A surveyor cited me because he says the door has to be constructed of non-combustible or limited combustible materials. The door that is installed is a high pressure decorative laminate with a bonded agri-fiber core with a 45 minute fire resistance rating. I maintain that doors are exempted from the noncombustible/limited-combustible provision. Who’s correct?

A: One scenario that the surveyor may hold you accountable to is medical gas systems in ambulatory care occupancies are regulated by the Life Safety Code, and not by NFPA 99. The Life Safety Code (2000 edition) would look at medical gas room as a hazardous room, and for ambulatory care occupancies, a hazardous room compares their level of hazard to their surrounding area. The section that regulates hazards in ambulatory care occupancies is section 20/21.3.2 which refers you to 38/39.3.2, which in turn refers you to section 8.4. Section 8.4 essentially says any area with a higher level of hazard than the surrounding area needs to be protected with fire protection sprinklers, or 1-hour fire rated barriers. Section requires a 1-hour fire rated barrier to have at least a ¾ hour fire rated door as long as the fire barrier is not used as a vertical opening (such as a rated shaft) or an exit enclosure (such as a stairwell). Hopefully, you don’t have the med gas room in a stairwell, so a properly labeled ¾ hour rated doors is acceptable, and in this scenario I would say the surveyor is mistaken. However, if the surveyor requires that you comply with NFPA 99 in regards to medical gas systems, then that is an entirely different situation. Section 4- (a) 11 (a) of the 1999 edition of NFPA 99 requires doors to be constructed of non-combustible or limited combustible materials. If the 45-minute fire rated door that you have is laminated with limited combustible materials, then it would not be compliant with NFPA 99 (1999 edition), and I would say the surveyor is correct. Section 3.3.118 in the Life Safety Code defines what limited combustible materials are. I suggest you contact the manufacturer of the door and ask them to produce documentation whether or not the door meets the heat values stipulated in section 3.3.118, that may qualify the door as being constructed with limited combustible materials. Now, on another point of view, if the surveyor requires you to comply with NFPA 99, 2005 edition, the door to this room still has to be constructed from non-combustible or limited combustible materials, but it is no longer permitted to be ¾ hour fire rated, but must be 1-hour fire rated, according to section The 2012 edition of NFPA 99 has the same requirement.

Medical Gas Shutoff Valves

imagesZ7K8PIAPI was recently a bystander amongst a discussion of healthcare facility industry experts, debating the NFPA requirements concerning the accessibility of medical gas shutoff valves in healthcare institutions. The original question asked was where does it specifically state that a medical gas zone valve box cannot have a wheeled obstruction in front it of it? While it is intuitive to keep the area in front of the shutoff valves clear, the question was a good one, as it appears the NFPA codes and standards do not specifically address the requirement to keep it clear.

The discussion that ensued was informative, as various standards were referenced as to support the opinion of the presenter. For example; Joint Commission standard EC.02.05.09, EP 3 says the valves must be accessible. But TJC does not define what ‘accessible’ means. According to the online dictionary, accessible is a place which is able to be reached or entered. So, if a wheeled gurney is placed in front of a medical gas shutoff valve, is it still accessible, if staff can reach over the gurney and actuate the valve? Or, is the shutoff valve still accessible if the gurney can be moved so staff can reach the valves?

The only one who can answer that question is the authority who is enforcing that standard, which is The Joint Commission in this case, but the other accreditation organizations have similar standards and they make their own interpretations as well. According to most of those in the discussion, Joint Commission and the other accreditation organizations are writing up hospitals and ambulatory surgical centers that have anything placed in front of the medical gas shutoff valves.

Another individual referenced NFPA 99, 1999 edition, which governs medical gas systems for healthcare institutions. Section 4- (i) which requires manual shutoff valves in boxes to be installed where they are visible and accessible at all times; the boxes should not be installed behind normally open or normally closed doors, or otherwise hidden from plain view. This description would seem to support the concept that the definition of accessible could include a wheeled object to be placed in front of the valves as long as the valves were accessible. At the least, it doesn’t seem to prohibit that.

But yet another individual said take a look at NFPA 99 (1999 edition), section 4- (d) on zone valves. For sake of clarity, I will repeat it here word-for-word (bold emphasis is mine):

Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet. This valve shall be readily operable from a standing position in the corridor on the same floor it serves. Each lateral branch line serving patient rooms shall be provided with a shutoff valve that controls the flow of medical gas to the patient rooms. Zone valves shall be arranged that shutting off the supply of gas to one zone will not affect the supply of medical gas to the rest of the system. A pressure gauge shall be provided downstream of each zone valve.

The above description is found under a section titled “Zone Valve”. The bolded section in the above description refers to the requirement of a manual shutoff valve that is located on the same story which is readily operable from a standing position in the corridor. That’s not necessarily the zone valve, but why isn’t this description also included in section 4- (i) which describes shutoff valves? The 2012 edition of NFPA 99 further elaborates on ‘Zone Valves’ and describes them in the same way that most people think of shutoff valves.

According to the online dictionary, the word ‘readily’ means without difficulty or delay; easily or quickly. So section 4- (d) of NFPA 99 (1999 edition) makes it pretty clear that the manual shutoff valve for the room outlets must be operated easily, and without delay. Parking a wheeled gurney in front of a medical gas shutoff valve could easily delay the operation of the valve; or at the minimum, it would provide a hindrance to the operation of the valve. Therefore, the wheeled gurney (or any other object) would not be permitted to be placed in front of the medical gas shutoff valves.

I think the accreditation organizations have got this issue correct. Anything that blocks access to a medical gas shutoff valves (whether it is called a shutoff valve or a zone valve) hinders the ‘readily operable’ capability of the medical gas valves, and would be a citable offense.


Clarification from The Joint Commission

Did you notice the January 29, 2012 issue of the Joint Commission Online? Among other articles, they had an article called “Clarification of storage requirements for freestanding medical gas cylinders.” In this article, they said improper storage of medical gas cylinders poses a number of hazards to patients and staff, which is true.

In fact, I don’t disagree with anything stated in the article. It’s all good stuff. But if you read the online article, you might be a bit confused. First, the article states that their standards EC.02.06.01, EP 1, and EC.02.03.01, EP 1 both require compliance with the NFPA requirements (presumably they mean on gas cylinder storage). A review of these two standards do not mention anything about NFPA standards or requirements. They do mention (generally speaking) that interior spaces need to be safe and suitable, and the hospital minimizes the potential for harm. Now, failure to properly store medical gas cylinders can easily be scored under either of these two standards, but to the point of the online article, there is nothing in these two standards that requires compliance with any NFPA requirement.

The January 29, 2014 online article does say that NFPA 99 (1999) section 4- mandates requirements for storing nonflammable gas cylinders, which it does. But NFPA 99 (1999) 4- says if stored in the same enclosure, empty cylinders shall be segregated from full cylinders, and empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

However, in the online article, it says the Joint Commission requires organizations to segregate full, partial and empty cylinders by physically separating and clearly labeling the cylinders. Does this mean healthcare organization are required to have three means of separation: one for full cylinders; a second for partial cylinders; and a third for empty cylinders? Not sure…

The online article continues to say that once a cylinder valve is opened, it is considered empty, even if gas remains in the cylinder. The article did not say once the valve is opened the cylinder is considered partial. Therefore, one could deduct that you only need to have two separations: one for full cylinders; and a second for partials and empties.

But the article also says an organization can have a full rack, a partial rack, and an empty rack, as long as unopened cylinders are segregated from all opened ones. What does this mean?  Is Joint Commission requiring three racks: one for full; a second for partials; and a third for empties? I don’t think so, because the sentence starts with the words “An organization can…” The word ‘can’ does not imply a requirement. Also, the sentence just before that says “For storage purposes, any opened cylinders must be physically separated from full (unopened) cylinders.” That sentence did not mention anything about a separate rack for partials.

At best, this clarification from the largest accreditor of healthcare organizations is confusing. You might be thinking why didn’t I just contact Joint Commission directly and get this resolved? I wish I could. I have been shut-out of the information loop from the official Media Relations department, and they will not return my emails, or respond to my requests for information.

My advice on this issue: Make sure you segregate your full medical gas cylinders from other cylinders that are considered partial or empty. Provide two means of segregation wherever you store medical gas cylinders, and make sure they are separated by using different racks, physical barriers or color-coding the storage racks. I suggest you segregate your cylinders into two different storage areas (instead of three) because that is what NFPA 99 suggests.

Incidentally, the requirement for healthcare organizations to comply with NFPA 99 (1999 edition) comes from sections 18/ of the 2000 Life Safety Code, and compliance with the LSC is required under Joint Commission standard LS.01.01.01. It is also covered under LS.02.01.30, EP 25.

CO2 Gas Manifold

Q: We have a situation in our Lab where they would like to purchase another incubator that requires additional CO2 gas.  The problem is that we do not have a designated space for storing more than 1 H size cylinder.  We have a space that is used to store flammable agents and is a two hour fire rated room with a fire suppression system, exhaust and the doors are equip with door closures.  Very little amounts of flammable agents are stored in this room anymore. Could we use this room as our gas manifold room for the CO2 gas?

A: NFPA 99 (1999 edition), section 4- is the code reference where oxidizing gases used in a manifold system are not allowed to be stored with anything else. Though, in your example you want to create a manifold system for CO2, which of course is not an oxidizing gas. I do not see anything in NFPA 99 that would prevent you from using this room for the CO2 compressed gas manifold system. However, it would be best to have the flammable agents stored inside a fire-rated metal storage cabinet.

Medical Gas Shutoff Valves

Medical Gas Shutoff Valves Blocked by Door Web 2

I received this picture recently from a good friend who works in a hospital, and is responsible for plumbing and power plant operation. He wanted to know if the medical gas shutoff valves which are located behind this door, are permitted since the valve box can be seen through the window in the door.

Apparently, the hospital installed new smoke compartment barrier doors in this area, and the previous doors were single-egress doors, which means both doors swung in the same direction. Well, according to section 4.6.7 of the Life Safety Code (2000 edition) when you make alterations and install new equipment, you must meet the conditions of the new occupancy chapter of the Life Safety Code, which in this case would be Chapter 18. Section 18. 3.7.5 requires new cross-corridor smoke compartment barrier doors to swing in opposite directions, or as commonly called, dual egress.

So, what happens in so many hospitals where the project team is not part of the facilities management team, some things get built or installed without the consultation and knowledge of those individuals who know the codes and standards the best. Now, I suspect my friend who sent me this picture knew the answer to the question before he sent it. At times, people need the assistance from consultants in order to emphasize the need for their own fellow employees to take action.

So, for those who may not know the answer… No. This condition is not acceptable.  According to section 4- of NFPA 99 (1999 edition), the shutoff valves must be installed where they are visible and accessible at all times. The [valve] boxes must not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

So what we see in the picture would likely be cited by a surveyor or inspector, especially since they can partially see the shutoff valve box through the window in the door. My friend says he will move the valve box, but I suspect that will cost quite a bit of funds, and a certain amount of medical gas interruption for the nursing unit. Not the best way to run projects.

Medical Gas Shutoff Valves

Q: I came across a medical gas shutoff valve that was located behind an access panel in a small storage closet in a surgery department. The closet was packed and equipment was blocking the access panel. There was no signage. Do you know if this is permitted or is it breaking a bunch of rules as it seems to me?

A: You are correct… This is way wrong. What you described is a zone valve and NFPA 99 (1999 edition) section 4- (d) requires zone valves to be readily operable from a standing position in the corridor on the same floor that it serves. Section of the 2000 edition of the Life Safety Code requires the hospital to be in compliance with NFPA 99 for “medical gas storage and administration areas”. The phrase ‘administration areas’ is all inclusive of the medical gas supply system, which means you must comply with NFPA 99 even for existing conditions. My advice to you is to relocate the valve to the corridor in accordance with NFPA 99, and provide adequate signage as to the areas that it serves.

Medical Gas Shut-Off Valves

Q: What is the distance needed to prevent obstructing medical gas shut-off valves?  Is it just not having anything directly in front of the valve itself – or does it have to be a certain distance away on each side?

A: This is a judgment call as there is not a specific distance identified for clearance in front of or to the side of medical gas shut-off valves. Section of the 2000 edition of the NFPA 101 Life Safety Code (LSC) requires medical gas systems to be in compliance with NFPA 99 (1999 edition) Standard for Health Care Facilities. Section 4- (d) in NFPA 99 requires zone valves (another name for shut-off valves) to be readily operable, and does not mention any specific clearance requirements in inches or feet. The definition of what is readily operable is left up to the authority having jurisdiction (AHJ) to decide, and our opinions don’t count (unless you are an AHJ!). In my experience, I have observed many AHJs using 3 feet clearance in front of the medical gas shut-off valves as a reasonable definition of readily operable. The 3 feet distance is widely believed to be taken from NFPA 70 the National Electric Code, in describing the clearances required in front of electrical panels.

Liquid Oxygen Transfilling

Ever see any of these devices in your hospital? If so, special needs and precautions are required to continue to use them.

These devices contain liquid oxygen  and they are specifically used to transfer liquid oxygen from this reservoir to portable hand-held canisters that would be used for individuals. That process is referred to as ‘transfilling’ and is highly regulated.

Liquid oxygen is a very dangerous material and the storage and use of liquid oxygen needs to be clearly defined in your hazardous materials management plan.

Liquid oxygen by itself is not flammable, but an oxygen enriched atmosphere makes all the other materials around it much more combustible. These reservoirs are not pressurized in the sense compressed gas is pressurized at 2,000 psi. The liquid oxygen reservoirs are constantly venting gaseous oxygen into the room where they are stored. Above its critical temperature of -118 degress F, liquid oxygen will only exist as a gas. When it expands from a liquid to a gas, it occupies 860 times more volume as a gas than it did as a liquid.

The reason liquid oxygen is so dangerous, is if it were to be spilled, then any combustible material it comes into contact with will immediately ignite. Liquid oxygen boils at -297 degrees F (at standard atmospheric pressure), and it brings the ignition temperature of anything it comes into contact with down to the point where the material will ignite at room temperature. That is why the transfer of liquid oxygen is not permitted on a surface that has combustible materials, such as carpet, vinyl tile and even asphalt. It can only be transferred on concrete or ceramic surfaces.

Section of the 2000 edition of the Life Safety Code requieres compliance with the 1999 edition of NFPA 99 Standard for Health Care Facilities on issues involving medical gas. Section 8- of NFPA 99 requires compliance with the Compressed Gas Association (CGA) Pamphlets P-2.6 and P-2.7 on liquid oxygen transfilling and storage. In addition to the CGA requirements, NFPA 99 also requires the actual transferring of liquid oxygen to be separated from any portion of a facility where patients are housed, examined or treated by a 1-hour fire rated barrier. The transfilling area must be well ventilated, protected aith automatic sprinklers, and have ceramic or concrete flooring.