How to Assess the Risk with
your Ventilation System
Malcolm Thomas
01179221768 - 07814077474
Ventilation Risks – Breaking the Law!
• Health Acts – Patient Safety - Infections
• Health and Safety at Work Act
• CoSHH – Local Exhaust Ventilation (LEV)
• Advisory Committee on Dangerous Pathogens.
• Building Regs. – Fresh air; HTM’s & HBN’s
• Medicine Acts – Quality assurance
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HTM 03-01, Part B, Nominated Persons
• Designated Person
• Authorising Engineer (Ventilation) – AE(V)
• Authorised Person (Ventilation – AP(V)
• Competent Person (Ventilation – CP(V)
• Infection Control Officer
• Plant operator
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HTM 0301; B. Hierarchy of Authority
Designated Person
Appointed senior executive
(NHS Board level)
responsibility of service
Authorising engineer AE(V)
Appointed independent
professional engineer
(Specific to service)
Board senior operational
manager
Informed client
Authorised person AP(V)
Appointed qualified technical
engineer
(Specific to service)
Competent person CP(V)
Assessed and qualified
craftsperson
(Specific for service)
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Duties and Responsibilities
Designated Person
• Board level manager
• Direct link to Operational management
• Will communicate Board policy to Organisation
• Will require the service be provided
• Will require evidence that it has been
(Annual audit report)
• Will present strategic operational plan to board
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Duties and Responsibilities
Authorising Engineer (Ventilation) – AE(V)
• Expert in Healthcare Ventilation
• Independent of Board and its organisation
• Conducts an audit of ventilation provision
• Provides independent advice
• Recommends candidates for AP(V) and CP(V)
• Reviews reports and documentation
• May provide training for AP(V) and CP(V)
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Duties and Responsibilities
Authorised Person (Ventilation) – AP(V)
• Manager with knowledge of Healthcare Vent.
• Trained in the duties of an AP
• Appointed in writing by Designated person
• Implements policy procedures to ensure the
safe provision of ventilation in Healthcare
• Recommends candidates for CP(V)
• Overseas outside contractors standards
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Duties and Responsibilities
Competent Person (Ventilation) – CP(V)
• Craftsman / Technician grade
• Knowledgeable in Healthcare Ventilation
• Trained in the duties of an CP
• Appointed in writing by Designated person
• Carries out service and maintenance of
ventilation systems in a Healthcare setting
• May oversee internal and external work
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Duties and Responsibilities
Infection Control Officer
• Consultant Microbiologist or Designated
Infection Control Officer
• Advises Board on infection control issues
• Chairs Infection Control committee
• Provides support to AP(V) (who should be a
member of the Infection Control committee)
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Annual Audit of Ventilation
Element
Compliance
1
Management issues
2
Authorised Person
3
Competent Person
4
Infection Control
5
LEV systems
6
Critical Healthcare systems
7
Fire issues
8
Plant locations
9
Energy efficiency
10
Support issues
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Typical initial Audit report
Element 1) - Management Issues
Comment
Authorising Engineer (Ventilation) appointed?
Mr. C. Y. Arse – Director of
Estates
Yes – Malcolm Thomas
Authorised Person (Ventilation) appointed?
Nominated only
Competent Person(s) (Ventilation) appointed?
Nominated only
Infection Control Person appointed?
No
Inventory of LEV systems available?
No
Inventory of specialised healthcare systems?
No
Are all systems uniquely identified?
Not always
Is there an up to date condition survey?
No
Is there a system replacement programme?
No
Designated person
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Typical initial Audit report
Element 2) - Authorised Person (Ventilation)
Name
Position
Work location
Training records
Area / site of responsibility
Element 3) - Competent Person(s) (Ventilation)
Name(s)
Position
Work location
Training records
Area / site of responsibility
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Comment
Mr. I.M. Trying – Possible
Mr. N. Bothered - Possible
IT – Estate Manager
NB – Assistant Estate Manger
Nonsuch Hospital
IT - None
NB – 2 weeks Ventilation at
Eastwood Park c1992
No training but local knowledge
Nonsuch Hospital
Comment
Mr. E. Skives (Mech) – Possible
Mr. R. Keen (Elec) - Possible
ES – Mechanical craftsperson
RK – Electrical craftsperson
Nonsuch Hospital
ES – None
RK - None
Nonsuch Hospital
12
Typical initial Audit report
Element 5) - LEV Systems
Comment
Location of inventory
None (See Appendix 1)
Are all LEV systems listed?
No
Is each system clearly labelled and its area
served identified?
No
Does each system have a log book or
Information file?
General file of LEV system
annual inspection reports
Does the file contain design, commissioning,
and verification information?
See above
Does the file contain records of repair,
maintenance and routine inspections?
On maintenance system
computer
Is each system subject to a statutory
inspection every 14 months?
Yes (Hazards Ltd.)
Is there a designated “user” contact for each
system?
Department head
Is there a “Hand over / Hand back” and/or
PtW system in operation when work is being
undertaken on the system
Yes
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Preliminary Inventory of LEV systems
LEV
ID
Department
None
Estates
None
None
Fracture
clinic
None Endoscopy
LEV
location
Welding
shop
Carpenters
workshop
?
?
None Biochemistry ?
None
Histology inc
Mortuary
?
None Dental
?
None Pharmacy
Aseptic
suite
LEV Description
Comment
Welding fume extract
system
Multi point wood
working machinery
ducted extract system
Mobile plaster saw and
extract (DeSouter)
Crap
Decontamination room
No access – door locked
3 systems identified in annual
reports
This is not an LEV system
Fume cupboard
Safety cabinets, cut up
benches and fume
cupboards
8 systems identified in annual
reports
11 systems identified in annual
reports
I would expect to find a fume
cupboard or Class2 safety cabinet
in Pharmacy?
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Typical initial Audit report
Element 6) – Specialised Healthcare Systems
Comment
Location of inventory
None (See Appendix 2)
Are all specialised healthcare systems listed?
No
Is each system clearly identified/labelled
Yes
Does each system have a log book or
Information file?
No
Does the file contain design, commissioning,
validation and verification information?
No
Is each system subject to an annual
verification?
Yes
Is each system subject to routine
maintenance?
On maintenance system
computer
Is there a designated “user” contact for each
system
Department head
Is there a “Hand over / Hand back” and/or
PtW system in operation when work is being
undertaken on the system
Yes
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AHU with Plate Heat Exchanger
A ir
In take
G3
MD
P late H eat
E xch an g er
BPD
G3
TPE1
TPS1
E xtract fro m su ite
E xtract F an
COD
E lim in ato r
H
COD
VCD
D isch arg e
MD
+
Fog
D rain
P lan t ro o m floo r
+
F5
F7
S u pp ly F an
D rain
D rain
D rain
B attery
FD
+
D am p er
A tten u ato r
M D - M o to rised
V C D - V o lu m e co n tro l
C O D - C u t o ff
B P D - B y p ass
F D - Fire / S m o ke
R ecirc
F an s
F ilters
H
U C V can o p y
A n aesth etic
Room
P rep ro o m
C h iller
F ilter
O p eratin g T h eatre
+
H eat er
H u m id ifier
© 02/04
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MT
TS
16
UCV Theatre ventilation
SC R U B BA Y
SC R U B BA Y
THEAT RE 1
PS
PS
S U RG E O N S
PA N E L
U T IL IT Y
T h e a tre 2
UC V H O O D
E
E
PS
PS
PS
E X IT L O B B Y
PS
E
PS
E
A N A E S T H E T IC
PRE P RO OM
S
S
E
PS
PS
PS
E
C L E A N C O R R ID O R
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Typical initial Audit report
Element
Management Issues
Compliance
25%
Authorised Person(s) (Ventilation)
10%
Competent Person(s) (Ventilation)
10%
Infection Control Person
90%
LEV Systems
60%
Specialised Healthcare Systems
60%
Fire Issues
35%
Plant Locations
50%
Energy efficiency
35%
Support aspects
30%
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How did they do?
How would you do?
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