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 4-3.5.2.2(b) mandates requirements for storing nonflammable gas cylinders, which it does. But NFPA 99 (1999) 4-3.5.2.2(b)(2) 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 18/19.3.2.4 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.