SAMPLE POLICY AND PROCEDURE

Medical Gas Cylinder Storage in Patient Care Areas

Target Group: Original Date of Issue: Version
FACILITY NAME
1
Approved by: Date Last Prepared by: Effective Date
Approved/Reviewed:
TITLE OF NAME AND TITLE
APPROVING OF AUTHOR
AUTHORITY

Purpose
This standard operating procedure is applicable to oxygen and nitrous oxide cylinder storage in
patient care areas. For simplicity, references to oxygen cylinders include nitrous oxide cylinders.

Instructions
1.0 Gas Cylinder Fill Status
FULL* means cylinder pressure is 1800-2200 psig. The gauge arrow is in the “green.”
PARTIALLY FILLED means the cylinder pressure is 500-1800 psig. The gauge arrow is
between “red” and “green.”
REFILL means the cylinder pressure is less than 500 psig. The gauge arrow is in the “red.”
EMPTY* means the cylinder pressure is at or near 0 psig (<29 psig).

*Per the U.S. Department of Transportation.

2.0 General Requirement

All freestanding cylinders shall be stored in a rack, on a cart, in a portable cylinder holder, in a
gas cylinder storage cabinet, or secured with a chain to protect them.

3.0 Cylinders In-Use

Cylinders “in-use” are not counted in the aggregate volume calculation.

To define “in-use” versus “in-storage,” cylinders properly secured to a gurney, wheel chair, crash
cart, medical equipment, etc., are considered “in-use.” In addition, pursuant to CMS letter S&C-
07-10, an individual cylinder placed in a patient room for immediate use by a patient is “in-use.”
However, placing a cylinder in a patent room must be based on an assessed individualized need.
All other cylinders are considered “in-storage” and count in the aggregated volume calculation.

1
4.0 Storage Limits
Storage limits are based on the total volume of oxygen stored per smoke compartment, not
the number of cylinders.

Smoke compartments are typically delineated by self-closing fire doors located in the corridor.

A full E-size cylinder contains approximately 25 cubic feet of gas; a full H-size cylinder
contains approximately 249 cubic feet of gas.

The total volume of oxygen stored outside of an enclosed interior room or gas cylinder storage
cabinet shall not exceed 300 cubic feet (equivalent to 12 full E-size cylinders).

The total volume of oxygen stored within an enclosed interior room shall not exceed 3000 cubic
feet (equivalent to 120 full E-sized cylinders).A smoke compartment can have more than one
enclosed interior room designated for oxygen storage.

The total volume of oxygen stored within a gas cylinder storage cabinet shall not exceed the
design capacity of the cabinet. Gas storage cabinets are available in various sizes. Gas storage
cabinets are useful when the total volume of oxygen exceeds 300 cubic feet, but an enclosed
interior room is not available. A smoke compartment can have more than one gas cylinder
storage cabinet (e.g., one for full cylinders; one for partial/empty cylinders).

5.1 Enclosed Interior Room Standards

An enclosed interior room shall meet the following design standards:

 Noncombustible or limited-combustible construction (e.g., utility rooms)

 Electrical outlets, switches, and fixtures installed at least 5 feet above the floor
 Self-closing door with lock
 A precautionary sign, readable from a distance of 5 feet on each door, with the
following wording as a minimum: CAUTION – OXIDIZING GAS(ES)
STORED WITHIN – NO SMOKING

6.1 Use of Enclosed Interior Rooms

Oxygen cylinders shall be separated from combustible materials (e.g., paper, plastics, wood,
wall coverings, carpet, etc.) by one of the following:

 A minimum distance of 20 feet

 A minimum of distance of 5 feet if the entire room is protected by an automatic
sprinkler system

Note: The separation distance requirements do not apply to cylinders stored in gas cylinder
storage cabinets.

2
7.1 Gas Cylinder Storage Cabinet Standards
Gas cylinder storage cabinets shall meet the following design standards:

 Noncombustible construction having a minimum fire rating of ½ hour. Commercially

available gas cylinder storage cabinets meet this standard.
 A precautionary sign, readable from a distance of 5 feet on the door, with the following
wording as a minimum: CAUTION – OXIDIZING GAS(ES) STORED WITHIN –
NO SMOKING

8.1 Segregation and Signage

Full cylinders shall be segregated from partially filled and empty cylinders.

Signs installed on racks, carts, gas storage cabinets, individual cylinders, or within enclosed
interior rooms shall be used to clearly identify cylinder fill status as follows:

 FULL – white lettering on a green background

 PARTIAL/EMPTY – white lettering on a red background

PWO 14392

PWO 14394

3
For consistency, FULL cylinders should be stored on the LEFT. PARTIALLY FILLED and
EMPTY cylinders should be stored on the RIGHT.

9.0 PAR Levels

The end user department should establish PAR levels based on anticipated and historical use
data.

10.0 Inventory Control

This section applies to rack storage subject to the 300 cubic feet limit (not within an enclosed
interior room or a gas cylinder storage cabinet).

Storage racks are available in various sizes – 4, 6, 12, 16, etc.

The end user department shall ensure the 300 cubic feet limit is not exceed.

Inventory monitoring is not required if the total rack storage capacity is 12 E-size cylinders or
less.

Method 1
The sum of the cylinder pressure gauge readings shall not exceed 24,000 (unitless).

Step 1: For each cylinder in storage, record the pressure gauge reading.
Step 2: Sum the pressure gauge readings.
Step 3: If the sum of the pressure gauge readings is less than 24,000, PASS. If the sum of the
pressure gauge readings is greater than 24,000, FAIL.

Method 2
The total volume of gas in storage is determined by summing the individual volume of each
cylinder in storage. For convenience, the following conservative rule of thumb table can be
used to evaluate compliance:

(a) (b)
Full E Cylinders Partial/Empty Volume
E Cylinders* cubic feet
12 0 300
11 1 293
10 2 288
9 4 300
8 5 294
7 6 288
6 8 300
5 9 294
4 10 288
3 12 300
2 13 294
1 14 288
0 16 300
* Each partial/empty cylinder is considered ¾ full (1500 psig).
Page 4 of 6
Step 1: Count the number of full cylinders and find result in column (a)
Step 2: Find the corresponding number of partial/empty cylinders in in column (b).
Step 3: Count the number of partial/empty cylinders. If the number of partial/empty cylinders is
equal to or less than the value in column b, PASS.
Step 4: If the number of partial/empty cylinders exceeds the value in column (b), calculate the
total volume of gas as follows:

Calculated Volume = (#F)(25) + (#/3/4F)(18) + (#1/2F)(12) + (#1/4F)(6) + (#1/8F)(3)

Where: #F is the number of full cylinders (1800-2200 psig)
#3/4F is the number of ¾ full cylinders (~1500 psig)
#1/2F is the number of ½ full cylinders (~1000 psig)
#1/4F is the number of ¼ full cylinders (~500 psig)
#1/8F is the number of 1/8 full cylinders (~250 psig)

Step 5: If calculated volume is less than 300 cubic feet, PASS. If calculated volume is greater
than 300 cubic feet, FAIL.

11.0 Reuse of Partially Filled Cylinders

Partially filled cylinders can be reused consistent with anticipated flow rate and remaining
oxygen volume. The following table can be used to estimate approximate time remaining based
on flow rate.

Page 5 of 6
12.0 Stock Rotation
Cylinders should be used on a first-in, first-out basis.

13.0 Contaminated Cylinders

Cylinders may become contaminated with blood, body fluids, or other potentially infectious
materials. Decontaminate cylinders following local infection prevention policy and procedure
for low and intermediate disinfection.

Regulatory Requirement/References

National Fire Protection Association, NFPA 99-1999 section 4-3.5.2.2(b)

Joint Commission Environment of Care Standards

Oversight and Responsibility

Departments that purchase, receive, transfer, store, use, or manage medical gas cylinders are
expected to follow this procedure.

For assistance, contact a hospital Environment of Care Committee member or designated expert.

Other Background Information

Approved: NAME OF APPROVING COMMITTEE/INDIVIDUAL

Issuing office: NAME OF OFFICE/DEPARTMENT ISSUING THE POLICY

Page 6 of 6