How to Assess the Risk with your Ventilation System

Malcolm Thomas

01179221768 - 07814077474

NP's 5/14 2

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

NP's 5/14 3

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

NP's 5/14 4

HTM 0301; B. Hierarchy of Authority

Designated PersonAppointed senior executive

(NHS Board level) responsibility of service

Authorised person AP(V)Appointed qualified technical

engineer(Specific to service)

Authorising engineer AE(V)Appointed independent professional engineer(Specific to service)

Board senior operational manager

Informed client

Competent person CP(V)Assessed and qualified

craftsperson(Specific for service)

NP's 5/14 5

Duties and ResponsibilitiesDesignated 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

NP's 5/14 6

Duties and ResponsibilitiesAuthorising 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)

NP's 5/14 7

Duties and ResponsibilitiesAuthorised 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

NP's 5/14 8

Duties and ResponsibilitiesCompetent 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

NP's 5/14 9

Duties and ResponsibilitiesInfection 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)

NP's 5/14 10

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

NP's 5/14 11

Typical initial Audit reportElement 1) - Management Issues Comment

Designated person Mr. C. Y. Arse – Director of Estates

Authorising Engineer (Ventilation) appointed? 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

NP's 5/14 12

Typical initial Audit reportElement 2) - Authorised Person (Ventilation) Comment

Name Mr. I.M. Trying – PossibleMr. N. Bothered - Possible

Position IT – Estate ManagerNB – Assistant Estate Manger

Work location Nonsuch HospitalTraining records IT - None

NB – 2 weeks Ventilation at Eastwood Park c1992No training but local knowledge

Area / site of responsibility Nonsuch Hospital

Element 3) - Competent Person(s) (Ventilation) CommentName(s) Mr. E. Skives (Mech) – Possible

Mr. R. Keen (Elec) - PossiblePosition ES – Mechanical craftsperson

RK – Electrical craftspersonWork location Nonsuch HospitalTraining records ES – None

RK - NoneArea / site of responsibility Nonsuch Hospital

NP's 5/14 13

Typical initial Audit reportElement 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

NP's 5/14 14

Preliminary Inventory of LEV systemsLEV ID

Department LEV location

LEV Description Comment

None

Estates

Welding shop

Welding fume extract system

Crap

NoneCarpenters workshop

Multi point wood working machinery ducted extract system

No access – door locked

NoneFracture clinic

?Mobile plaster saw and extract (DeSouter)

3 systems identified in annual reports

None Endoscopy ? Decontamination room This is not an LEV system

None Biochemistry ? Fume cupboard

NoneHistology inc Mortuary

?Safety cabinets, cut up benches and fume cupboards

8 systems identified in annual reports

None Dental ?11 systems identified in annual reports

None PharmacyAseptic suite

I would expect to find a fume cupboard or Class2 safety cabinet in Pharmacy?

NP's 5/14 15

Typical initial Audit reportElement 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

NP's 5/14 16

AHU with Plate Heat Exchanger

UCV canopy

Operating Theatre

MTTS

+

+

+

+

-

-

H

H

©02/04

Filter

Heater

Chiller

Attenuator

Humidifier

Damper

MD - MotorisedVCD - Volume control

FD - Fire / Smoke

COD - Cut offBPD - By pass

F7

F5FogBattery

Prep room

IntakeAir

Supply Fan DrainDrainDrain

Drain

G3 G3BPDPlate Heat

Exchanger

VCDCODCOD

MD

MD

Extract from suite

Extract Fan

Discharge

TPS1TPE1

FDPlant room floor

AnaestheticRoom

Eliminator

RecircFansFilters

17NP's 5/14

UCV Theatre ventilation

ANAESTHETICPREP ROOM

THEATRE 1

UCV HOOD

SCRUB BAYSCRUB BAY

SURGEONSPANEL

E

E

E E

E

E

PSPS

PS

PS

PSPS

PS

PS

PSPS

CLEAN CORRIDOR

SS

UTILITY

EXIT LOBBY

Theatre 2

NP's 5/14 18

Typical initial Audit report

Element Compliance

Management Issues 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%

NP's 5/14 19

How did they do?

How would you do?