HSIB's investigation into oxygen issues during COVID-19

Medical air outlets

The Healthcare Safety Investigation Branch (HSIB) recently launched a national investigation into the provision of piped oxygen gas supplies to hospitals and have published an interim report highlighting early findings.

The report looks at the significant pressure that the pandemic has put on the ability of medical gas pipeline systems to deliver the volume of oxygen required to patients, leading to one Trust diverting patients to different hospitals, elective surgery being cancelled, and a need to reconfigure ward environments.

HSIB state that this event highlighted a national safety risk with MGPS possibly unable to meet the anticipated output due to factors related to the COVID-19 pandemic. As a result, it has authorised a full investigation. This will explore the issues relating to the limitations in piped oxygen supply to hospitals and the role of engineering specialists and Medical Gases Committee in this, aiming to identify any safety action or learning that could assist in mitigating the risk to piped oxygen supplies.

The ‘Oxygen issues during the COVID-19 pandemic’ bulletin, released in January 2021, highlights a number of considerations for the urgent attention of NHS Trusts.

  • VIE capacity (or a subcomponent within the VIE) is not necessarily the limiting factor in delivering required levels of oxygen into hospital via MGPS.
  • Demand issues can occur even where VIE capacity is well within expected parameters. Existing pipework infrastructure, where patients on oxygen therapy are placed within the hospital estate, and the variable amounts of oxygen used by different equipment can limit the available volume of oxygen gas in different clinical areas.
  • Real time monitoring of oxygen flow and suitable pressure alarms in individual clinical areas may support efficient management of MGPS loading.
  • Cohesive senior clinical, operational, estates and pharmaceutical leadership is required to ensure there is a shared understanding about the limitations in the local MGPS across all clinical areas and how these may directly impact on clinical decision-making and patient safety.
  • Executive boards should take urgent action to ensure that trusts have fully understood and complied with alerts and guidance from NHS England and NHS Improvement, and the NHS Specialist Pharmacy Service, on how to manage demands on MGPS.

HSIB stress that these considerations should be view alongside existing alerts, guidance and support.

Once clear, evidence-based guidance is published, Eastwood Park will look to incorporate this into its medical gas training.

Reference

https://www.hsib.org.uk/investigations-cases/oxygen-issues-during-covid-19-pandemic/

https://www.hsib.org.uk/documents/275/HSIB_Bulletin_Oxygen_issues_during_COVID-19_pandemic_v08.pdf