Q: Several of our department have stretchers with onboard E-size oxygen cylinders. Can these be considered “in use” and not count against the smoke compartment’s 300 cubic feet limit? Also, our nursing staff currently checks oxygen inventory daily and documents it on a log. Is this a written code requirement?
A: Yes and No. All O2 cylinders that are mounted on gurneys, wheelchairs and medical equipment but are not actively used by patients are considered by CMS to be in use, and therefore are not subject to the 300 cubic feet threshold for stored medical gas cylinders. They explained their position on this issue in a memorandum called S&C-07-10, dated January 12, 2007. The Joint Commission has endorsed this position as well and has said as much at various opportunities. In regards to the nurses checking oxygen levels on a daily basis, I am not aware of any LSC or Joint Commission requirement for this action. Perhaps there may be something about this from the state. I do know that plant operators frequently record the level of liquid oxygen in the bulk storage tanks but that is more for tracking purposes and to ensure they do not run out.