Medical Gas Committees: their role, responsibilities, and membership

Tim Root, Assistant Head, Medicines Assurance, NHS Specialist Pharmacy Service, Specialist Pharmacy ServicePublished
Topics: Medical gases

Describes why Medical Gas Committees are required, suggested membership and ToR, and their role during the pandemic

Why Medical Gas Committees are important

Both HTM 02-01 and (s)HTM 02-01 recommend that a Medical Gas Committee be established to “oversee the general operation and management of the Medical Gas Pipeline System and all facets of the MGPS operational policy”. The requirement to have a multidisciplinary group (such as a Medical Gas Committee) responsible for reviewing oxygen-related incidents, developing a local oxygen policy and a training programme was reinforced within the National Patient Safety Agency Rapid Response Report (NPSA/2009/RRR006).

Membership

The Medical Gas Committee should include:

  • Chief Pharmacist/Director of Pharmacy or senior deputy with appropriate knowledge and decision making authority
  • Authorised Person (MGPS) (may be NHS Trust, Board or PFI)
  • Authorising Engineer (MGPS, Co-ordinating)
  • Head/Director of Estates or senior deputy
  • Other relevant Pharmacy Manager e.g. Procurement
  • QC (MGPS)
  • Medical Physics/EBME
  • Facilities/Portering
  • Clinical representation including Senior Nursing Staff / Anaesthetists / Clinicians
  • Primary medical gas supplier representative

The Chair of the committee may be the Authorised Person (MGPS) (ref HTM 02-01 para 7.78)

However, Mitigating the effect of COVID-19 on the performance of Healthcare Cryogenic Liquid Oxygen Systems is specific in the recommendation that the Chair should be the Chief Pharmacist.

Committee members should have the appropriate knowledge and skills and have the authority to act. In addition membership should include those involved in planning and directing clinical pathways during periods of increased oxygen demand and usage.

Terms of reference and accountability

Accountability and governance reporting lines for the Medical Gas Committee should be established to ensure actions are escalated as required to the appropriate level within the organisation. A “terms of reference” document should be developed and approved.

The committee’s role in planning oxygen requirements for patients during a pandemic

Co-ordinate all activity

The Medical Gas Committee should co-ordinate all activity related to management of oxygen during and after a pandemic. It may also be appropriate to establish an oxygen resilience sub-group or equivalent to focus specifically on the challenges presented by a pandemic and link to wider emergency preparedness organisational structures.

Specific tasks

Medical Gas Committees should also :-

  • Prepare a site resilience/contingency plan and identify areas where high oxygen demand can be accommodated. Site plans illustrating this along with areas that have been closed may be helpful. A Standard Operating Procedure detailing action to be taken at strategic points of elevated demand should be prepared. Ensure roles and responsibilities have been identified. “Table top exercises” should be implemented to test the plan before it is needed and to identify risks and areas for improvement. Our article
    Management of Oxygen during periods of high demand will be useful.
  • Develop and maintain organisational policies and procedures.
  • Actively review cylinder management policies, cylinder stocks, processes for efficient stock movement. Processes to ensure that empty cylinders are returned to the cylinder store immediately to be returned to the supplier for re-filing are essential.
  • Ensuring plans are in place to recover cylinders sitting unused, which may be utilised elsewhere on site to support patients with lower oxygen requirements, with the aim of pulling less gas from the piped system.
  • Developing local ‘good housekeeping’ guides to support the provision of simple messages and approaches to preserve supplies and effectively manage medical gases. Turning off and removing oxygen flowmeters which are not in use is a simple but effective way of reducing wastage. An example good housekeeping guide is available.
  • Education and training – this is a significant risk within organisations which needs urgent attention.
  • Ensure associated risks are recognised, documented and action taken to minimise them. Review incidents and promote staff engagement in incident prevention.
  • Co-ordinate actions in response to Safety Action Notices, EFA alerts etc
  • Provide assurance to (governance report), stakeholders and other governance groups that medical gases are effectively managed

Further guidance

Appropriate use of medical gases is important. View our guidance page and other resources.

Materials to support safe and appropriate supply, administration, monitoring and equipment issues