UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Oxygen Storage and Safety
Policy 7.4.19
Page 1 of 4
Oxygen Storage and Safety
Formulated: 06/88
Effective:
Revised:
Reviewed:
11/06/94
1/24/03
9/16/05
Oxygen Storage and Safety
Purpose
To outline the oxygen storage, delivery and responsibilities of oxygen
cylinders and adjunctive equipment and requirements for the bulk oxygen
system.
Audience
Respiratory Care Service employees.
Scope
Guidelines for the storage, delivery and usage of the bulk oxygen system
and cylinders.
Procedure
Step
Action
1
Bulk Oxygen Storage
 The bulk oxygen storage is located above ground and
out of doors.
 The locations are such that containers and associated
equipment are not exposed near electrical power lines,
flammable or combustible liquid lines or flammable
gas lines.
 The unit is located so that automobiles and other
vehicles cannot damage it.
 It should not be located over sewers, open drains, gas
lines or underneath electrical lines.
2
Outside Oxygen Cylinder Bank
 An outside manifold for the oxygen cylinder bank is
placed in wire fencing. It is designed so there is an
operating bank and a "reserve" bank that changes over
automatically.
3
Shut Off Valves (Zone Valves) - All shut-off valves
accessible to other than authorized personnel should be
installed in valve boxes with frangible windows large
enough to permit manual operation of the valves in an
emergency. Respiratory Care Services will know the
location of all zone valves. Each zone valves should be
labeled as follows:
Caution - Oxygen Valves - Do Not Close Except in an
Emergency - This Valve Controls Oxygen Supply To:
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Oxygen Storage and Safety
Policy 7.4.19
Page 2 of 4
Oxygen Storage and Safety
Formulated: 06/88
Effective:
Revised:
Reviewed:
11/06/94
1/24/03
9/16/05
Procedure
Continued
Step
Action
4
Types of Shut Off Valves (Zone Valves)
 Main-Line-Shut-Off-Valve - A shut-off valve should
be provided in the main oxygen delivery line leading
from the oxygen supply unit. This valve permits
cutting off the entire oxygen supply from the hospital
in case of emergency.
 Riser-Shut-Off-Valve - Each branch line leading from
a riser to patient outlet stations should be equipped
with a branch line shut-off valve located on the same
floor as the outlet it controls.
 Branch-Line-Shut-Off-Valve - Each branch line
leading form a riser to patient outlet stations should be
equipped with a branch line shut-off valve located on
the same floor as the outlet it controls.
 Zone valves will be shut off only under direct
administrative orders or if impending disaster is
evident.
5
In-House Cylinder Storage
 An oxygen storage room will have a one-hour fire
resistance rating.
 It will be vented to the outside of the building.
 The room will not open directly into locations where
combustible anesthesia gases are used or stored.
 Combustible materials and petroleum based materials
such as oil, alcohol, paint, ether, ethylene or
cyclopropane will not be stored in the same room with
oxygen.
 Oxygen therapy apparatus and supplies and nonflammable gases such as nitrogen, carbon dioxide,
carbon dioxide-oxygen mixtures, helium-oxygen
mixtures and nitrous oxide are permitted.
 Oxygen therapy apparatus and supplies and nonflammable gases such as nitrogen, carbon dioxide,
carbon dioxide-oxygen mixtures, helium-oxygen
mixtures and nitrous oxide are permitted.
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Oxygen Storage and Safety
Policy 7.4.19
Page 3 of 4
Oxygen Storage and Safety
Formulated: 06/88
Effective:
Revised:
Reviewed:
11/06/94
1/24/03
9/16/05
Procedure
Continued
Step
5
Continued
Action




Smoking and all other sources of ignition are
prohibited in the area.
Full, half-empty, and empty cylinders will be kept in
different sections of the storage room.
Cylinders of non-flammable gases will be clearly
marked and kept separate from oxygen cylinders.
Oxygen cylinders will not be stored near sources of
heat such as boilers, furnaces, steam pipes or
radiators.
6
Handling Cylinders
 Cylinder valves will be kept closed even when the
cylinder is considered empty.
 Valve protection caps will be in place except when
the cylinder is actually in use.
 Never attempt to pick up a cylinder by the valve cap,
except to raise it from a horizontal to vertical
position.
 When oxygen cylinders are used within a hospital,
they will be securely strapped in an oxygen truck.
7
Use of Oxygen Cylinders
 Be sure that your hands or gloves are clean and free
of oil or grease before you touch any oxygen
apparatus.
 Whenever oxygen is used from a cylinder, a
regulator must be attached to reduce the high
pressure of the oxygen coming from the cylinder.
Never administer oxygen from a cylinder without a
regulator.
Always clear the particles of dust and dirt form the
cylinder valve openings by slightly opening and closing
the valve before applying and fitting it to the cylinder.
Open the high-pressure valve on the oxygen cylinder
before bringing the apparatus to the patient.
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Oxygen Storage and Safety
Policy 7.4.19
Page 4 of 4
Oxygen Storage and Safety
Formulated: 06/88
Effective:
Revised:
Reviewed:
11/06/94
1/24/03
9/16/05
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Oxygen Storage and Safety
Policy 7.4.19
Page 5 of 4
Oxygen Storage and Safety
Formulated: 06/88
Effective:
Revised:
Reviewed:
11/06/94
1/24/03
9/16/05
Procedure
Continued
Step
7
Continued
Action

Open the cylinder valve slowly, with the face of the
gauge on the regulator pointed away form any
person.
 When a cylinder is delivered to a patient's room, it
will be placed in a cylinder stand.
 The NO SMOKING rule must be enforced strictly. A
NO SMOKING sign should be placed on the door of
a unit in which a patient is receiving oxygen and a
NO SMOKING sign shall be placed inside the
patient room in plain view, near the oxygen wall
outlet.
 Before delivering an oxygen cylinders to a patient's
room, calculate the duration of gas available with the
following formula:
E Cylinder: PSIG X .3 = # of minutes of service
LPM
H Cylinder: PSIG X 3 = # of minutes of service
LPM
References
Egan's Fundamentals of Respiratory Care, 8th Edition Eighth Edition,
Mosby; June 2, 2003
Jimmy M. Cairo, Susan P. Pilbeam, Respiratory Care Equipment Mosby;
6th edition (March 15, 1999)
UTMB Institutional Handbook of Operating Procedures: Sentinel Events
Policy # 9.13.16, http://www.utmb.edu/policy/ihop/search/09-13-16.pdf
JCAHO: Management of the Environment of Care; EC.1.7, Medical Gas
Management http://www.utmb.edu/JCAHO/