An investigation has been completed by the Healthcare Safety Investigation Branch into the provision of piped oxygen gas supplies to UK hospitals, concluding that improvements could be made to existing infrastructure in order to ensure that hospitals meet oxygen flow needs.
The report, titled ‘Oxygen issues during the Covid-19 pandemic’, endeavoured to investigate limitations in piped oxygen supply to hospitals and explore the role of engineering specialists and medical gasses committees in piped oxygen supply.
The investigation explored a reference event where a major incident was declared by an acute hospital trust (Trust) when oxygen supply demands, delivered via its medical gas pipeline system (MGPS), led to patients being diverted to different hospitals, elective (planned, non-emergency) surgery being cancelled, and a need to reconfigure ward environments.
Further to this, the report states that the Trust began identifying mitigating measures that would allow it to carry out a test on the MGPS in the High Dependency Unit (HDU). It also states that the Trust carried out a pressure test on the MGPS to identify failures, with the results identifying several areas where there was a reduced ability to provide the anticipated flow of oxygen from the MGPS.
Despite the Trust understanding that the HDU should have been capable of provindg a specified flow of oxygen to a certain number of patients, the report discovered that the anticipated flow of oxygen to the HDU, and other wards, was impacted by an influx in earlier oxygen demand from the MGPS system before the pipeline reaching the HDU.
It was found that the Trust had spare capacity to generate oxygen as the overall demand on the MGPS never exceeded more than 56% of its total capacity. Therefore, the investigation concluded, the limitations in the Trust’s existing pipework infrastructure contributed to the lack of oxygen flow available to the HDU.
Other contributing factors included the distribution of patients across the hospital, and the types of oxygen therapy required to treat patients across the hospital.
From the investigation, the report suggests several solutions that could be examined in order to prevent future oxygen shortages from occurring when needed most. One of the key findings was the lack of investment into the MGPS itself, with one safety observation suggesting it ‘may be beneficial if medical gas pipeline systems were prioritised for financial investment and ongoing management where they may not be effective for future anticipated clinical needs.’
It was also suggested that key technical documents should be updated to reflect recent developments in healthcare. The report noted that the last update to the MGPS health technical memorandum was 2006.
Dr Stephen Drage, Director of Investigations at HSIB, said, “Our investigation highlighted just how critical the MGPS is and that if it fails the impact is significant.”
“Any uneven demand in the pipework could mean that a concentration of oxygen in one area – for example to Covid-19 patients – could lead to a reduction elsewhere. Patient wellbeing can be at further risk as may have to make tough decisions about prioritisation of care to ensure that sufficient oxygen is distributed across the hospital.”
“We recognise the speed at which the NHS had to adapt to this unprecedented demand.”
He went on to make it clear that the report is not aimed at criticising the response to oxygen supply issues, but to examine and understand why existing measures were not able to address the risks to the MGPS.
The full report can be accessed here