'Lack of shared ownership and knowledge' exacerbated oxygen issues
A ‘lack of shared ownership and knowledge’ of medical gas pipeline systems among hospital-based multidisciplinary teams ‘limits Trusts’ ability to effectively respond to MGPS patient safety concerns’.
So says a recently published Healthcare Safety Investigation Branch report into oxygen pipeline issues during the coronavirus pandemic. The report identifies where ‘crucial improvements to planning, system design, and infrastructure’ could be made to ensure hospitals can always meet oxygen flow needs, ‘especially in times of crisis’.
An HSIB investigation launched in January identified that ‘the majority’ of hospital wards and departments had to accommodate patients with greater oxygen needs due to COVID-19; it was made aware of ‘at least a dozen’ NHS Trusts where concerns over oxygen were raised, and emergency action had to be taken to mitigate the risk. This issue was exemplified with the case of a hospital that declared a major oxygen provision incident during the pandemic’s second wave; ‘excessive demands’ on its MGPS led to ‘major disruption’, with patients diverted to other hospitals, and elective surgery cancelled. ‘It was not an issue with the amount of liquid oxygen available, rather the ability of the system to deliver the flow of oxygen required’, the report stressed.
The HSIB investigation not only examined the current engineering and technology systems in place to ensure medical gas pipeline systems operate effectively, but also explored ‘how well this crucial role is understood’ across hospital teams, and how MGPS safety is assured by regulators.
Key areas for learning and improvement identified included:
- Collaboration and communication: a need to create systems and processes to bring together clinical and non-clinical expertise within Trusts ‘to map and plan the MGPS to ensure the most effective use’. ‘The teams that worked across disciplines were ‘better able’ to respond to the demands created by COVID-19’.
- Updated design: systems should be designed in line with recent developments in healthcare, and key technical documents should be updated to reflect this – the HSIB noted, for example, that the last update to the MGPS HTM was in 2006.
- Rethinking infrastructure investment: Trusts said maintenance backlogs and the prioritisation of investment in estate ‘may have created extra challenges for MGPS that were not identified prior to COVID-19’. The report includes one safety observation suggesting that ‘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’.
The report concludes with four safety recommendations and four safety observations, all aimed at improving management and understanding of MGPS across the NHS. Three safety actions completed since the investigation started have also been included.
Dr Stephen Drage, the HSIB’s director of Investigations (pictured), 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 staff face 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, and our report is not aimed at criticising the response to oxygen issues; rather it is there to examine and understand why existing measures may not have been fully effective in addressing the risks to the MGPS. The investigation findings and resulting safety recommendations can help inform future responses to COVID-19 or other respiratory viruses.”