Oxygen planning and management- Hospitals

COVID 19- Medical Oxygen planning and management in hospitals

This presentation gives an overview of the oxygen sources, the supply systems, estimating the peak load and planning the systems and the disaster management in case of oxygen shortages in hospitals.

1. Dr. Lallu Joseph Quality Manager & Assoc. General Superintendent CMC Vellore CHRISTIAN MEDICAL COLLEGE VELLORE Oxygen Planning and Management

2. Anatomy of my presentation 1. Oxygen Sources 2. Supply of Oxygen/ Back up 3. Estimating Oxygen Needs 4. Current situation in Indian Hospitals 5. Planning of the system – Good Practices 6. Disaster Planning

3. 1. Liquid Medical Oxygen (LMO)

4. Liquid Medical Oxygen (LMO ) Cryogenic Source Most popular choice for big hospitals and hospitals with connectivity (good supply chain) Stringent licensing requirements Cleanest source > 99% pure Oxygen stored in liquid state At 15 Degree C, 1 L of liquid oxygen can produce 842 L of oxygen At 27 Degree C, 1 L of liquid oxygen can produce about 888 L of oxygen Bought in Kilogram (MT ), paid in cu.m of liquid, consumed in litres per minute (gas ). 1 kg is about 0.867 L of liquid 1 kg is about 0.769 cu.m of gas 1 cu.m is 1000 L of gaseous oxygen

5. Oxygen Manifold

6. Manifolds Manifolds – Main supply for small hospitals 1 st level of backup hospitals with LMO Right bank and Left bank- Pressurized D type cylinders – 6.7 cu.m (Nomenclature different in countries) Purity > 99% Common types of cylinders used in India A Type- 5L capacity of water- 1 cu.m oxygen ( Anaesthesia Machine) B Type- 10L capacity of water- 1.47 cu.m (Transport Cylinders) D Type- 44L capacity of water- 6.5-7 cu.m (Bulk Cylinders)

7. How many hours will it last? Gauge reads the pressure Full cylinder pressure = 138 bar Gauge reading = 130 bar (94% full) 94% of 6500 L of oxygen gas = 6110 L Patient on 2 LPM will receive 50 hours of oxygen supply Patient on 4 LPM will receive 25 hours of oxygen supply Patient on 10 LPM will receive 10 hours of oxygen supply If connected with ventilator, CPAP, BPAP it can work upto 6 bar If connected with flow meter with mask, nasal prong it can work upto 2 bar

8. Oxygen Concentrator

9. Oxygen Concentrator/ Generator Constant source Separates oxygen from atmosphere (Adsorbing under pressure) Adsorbent material - Zeolite ( aluminium silicate) Purity – 90% to 95% Argon with small quantity of nitrogen Purity good with 75- 80% load Two technology- PSA (Pressure Swing Adsorption) & VSA (Vacuum Swing Adsorption)

10. 2. Oxygen supply Three components/ backup Primary Supply Secondary Supply Reserve Supply Depends on the size of the hospital, complexity of operations and distance

11. Oxygen supply system Primary Supply Secondary Supply Reserve Supply Gas cylinder manifold Automatic manifold changeover system 1. Manual emergency cylinder manifold 2. Automatic system to provide 4 hours 1. Automatic manifold system to supply entire hospital 2. Automatic manifold for ICU LMO 1. Single vessel 2. One vessel of duplex system – same area 3. One vessel of duplex system – separate area 1. Automatic manifold system 2. Second vessel 3. Second vessel in separate area Automatic manifold – entire hospital/ ICU, HDU Oxygen concentrator Plant size as per hospital requirement Single vessel Automatic manifold system Automatic manifold – entire hospital/ ICU, HDU

12. Supply Layout

13. 3. Estimating oxygen needs Historical oxygen use Facility -level estimation To estimate the amount of oxygen an existing facility needs To estimate the amount of oxygen a facility will need Records of past oxygen use Number of general beds Number of critical care beds Or specific facility infrastructure plans * What is your goal? What are your data? Essential questions * Plan for 100% bed occupancy Source: WHO - Tools and resources for oxygen system planning and procurement

14. Determining peak flow Number of beds Flow rate ( LPM ) Required LPM Standard beds 700 0.75 525 Critical care beds 100 10 1000 Total 800 1525 1525 LPM = 10135 D Type cylinders per month or two 1000 LPM PSA/ VSA plants or two numbers of 5 KL LMO plants Average consumption is generally 35% - 40%

15. 4. Current situation in Indian Hospitals Source: Paul C, Paul J, Babu A. Hospital oxygen supply: A survey of disaster preparedness of Indian hospitals. Indian J Respir Care 2020;9:216-20. Primary Oxygen Supply Reserve Oxygen Supply Alarm systems

16. 5. Planning of the system – Good Practices Auto changeover from supply to backup Common mistake – single pipeline from the primary source Cylinder manifold should not be placed at the same site as the LMO or Oxygen concentrator Reserve supply at a different location even if both are manifolds Manifolds and concentrators (higher floors) at higher level to mitigate flood and other disasters Primary supply should meet requirement of atleast 4 days and reserve 3 days (B type cylinders are not reserves)

17. 6. Disaster Planning Hourly monitoring Oxygen conservation measures, Oxygen audit/ stewardship programs Offset loads- portable concentrators, reduce surgical load, frequent audit of pipelines and terminal ends, use of medical air instead of oxygen for anesthesia machines ( 400 LPH for an adult patient) Alert levels to be fixed Core oxygen monitoring group Escalation matrix Disaster management protocol