How to Assess the Risk with your Ventilation System Malcolm Thomas 01179221768 - 07814077474

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

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

HTM 0301; B. Hierarchy of Authority Designated Person Appointed 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 Board senior operational manager Informed client Competent person CP(V) Assessed and qualified craftsperson (Specific for service) NP's 5/14

Duties and Responsibilities Designated 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

Duties and Responsibilities Authorising 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

Duties and Responsibilities Authorised 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

Duties and Responsibilities Competent 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

Duties and Responsibilities Infection 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

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

Typical initial Audit report Element 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? Infection Control Person appointed? No Inventory of LEV systems available? Inventory of specialised healthcare systems? Are all systems uniquely identified? Not always Is there an up to date condition survey? Is there a system replacement programme? NP's 5/14

Typical initial Audit report Element 2) - Authorised Person (Ventilation) Comment Name Mr. I.M. Trying – Possible Mr. N. Bothered - Possible Position IT – Estate Manager NB – Assistant Estate Manger Work location Nonsuch Hospital Training records IT - None NB – 2 weeks Ventilation at Eastwood Park c1992 No training but local knowledge Area / site of responsibility Element 3) - Competent Person(s) (Ventilation) Comment Name(s) Mr. E. Skives (Mech) – Possible Mr. R. Keen (Elec) - Possible Position ES – Mechanical craftsperson RK – Electrical craftsperson Work location Nonsuch Hospital Training records ES – None RK - None Area / site of responsibility NP's 5/14

Typical initial Audit report Element 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? 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

Preliminary Inventory of LEV systems LEV ID Department LEV location LEV Description Comment None Estates Welding shop Welding fume extract system Crap Carpenters workshop Multi point wood working machinery ducted extract system No access – door locked Fracture clinic ? Mobile plaster saw and extract (DeSouter) 3 systems identified in annual reports Endoscopy Decontamination room This is not an LEV system Biochemistry Fume cupboard Histology inc Mortuary Safety cabinets, cut up benches and fume cupboards 8 systems identified in annual reports Dental 11 systems identified in annual reports Pharmacy Aseptic suite I would expect to find a fume cupboard or Class2 safety cabinet in Pharmacy? NP's 5/14

Typical initial Audit report Element 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? Does the file contain design, commissioning, validation and verification information? Is each system subject to an annual verification? 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 NP's 5/14

AHU with Plate Heat Exchanger NP's 5/14

UCV Theatre ventilation NP's 5/14

Typical initial Audit report Element Compliance Management Issues 25% Authorised Person(s) (Ventilation) 10% Competent Person(s) (Ventilation) Infection Control Person 90% LEV Systems 60% Specialised Healthcare Systems Fire Issues 35% Plant Locations 50% Energy efficiency Support aspects 30% NP's 5/14

How did they do? How would you do? NP's 5/14