Presented by: John Southall Senior Pharmacy Purchasing Technician MANAGEMENT OF MEDICAL GAS CYLINDERS at Southend University Hospital NHS Foundation Trust Presented by: John Southall Senior Pharmacy Purchasing Technician

History – How did we do it previously? Little or no cylinder management on wards. Often with cylinders hidden in cupboards and storerooms. No control over cylinder exchange with Ambulance crews. Simple full for empty ordering process.

What problems did this cause us? Overstocking of cylinders – we had no way of knowing the actual number of cylinders we had on site (were we paying rental on cylinders we didn’t need?) Migration of cylinders – cylinders were moving off site with ambulance crews. (were we paying rental on cylinders we didn’t have) Increased expenditure against budget.

What were the drivers for change? 1. Estates & facilities alert – ‘unsecured cylinders’ Alert relating to the death of a patient at another Trust, required the removal, or adequate securing of all large (G size) cylinders on wards. 2. To stop the loss of cylinders to other Hospitals via the ambulance network. 3. To devolve budget (and cost responsibility) to ward level.

How did we plan our process change? 1. Undertake a Trust wide audit. In conjunction with BOC to establish exact cylinder count. Sign-off document agreeing actual stocks on-site and agree a ‘write-off’ process.

How did we plan our process change? 2. Protect stock from off site migration. Created a dedicated and secure ‘Essex ambulance only’ store* and ordered BOC stock on their behalf. Refuse private ambulance crews access to Trust or Essex ambulance cylinder stores. *Now have their own central depot and order stock themselves.

How did we plan our process change? 3. Cylinder ‘write-offs’ Is there such a thing as a lost cylinder?.* In our case, we argued that cylinders were not lost but had simply been ‘taken’ by ambulance crews to other hospitals where they would eventually find their way back to BOC . Agreement on write-off was achieved in part because we found that where we were missing some cylinders, we were overstocked on others. *BOC barcode tracking should make this a thing of the past.

How did we plan our process change? 4. Adopt a Multidisciplinary approach. Nursing, Portering, facilities and Pharmacy staff all have an equal role to play in the process. Realise that engagement and education of these groups was vital to a successful outcome.

How did we plan our process change? 5. Agree ward stock lists. A team including Nursing director and senior matrons from Medical & Surgical, ITU and Theatres were asked to agree on appropriate cylinder stocks on a ward by ward basis. This took into account existing piped Oxygen supply.

How did we plan our process change? 6. Devolve budget to ward level. Once ward stock holding is agreed, we make individual wards accountable for the their stock. By realising the ‘asset value’, nursing staff begin to take more care of their cylinder stocks.

How did we plan our process change? 7. Create ‘drug files’ on JAC We decided to treat medical gas cylinders as we would any other prescribed drug and created drug files for rental and re-fill costs, assigning contract prices accordingly. e.g. ‘RENTAL OXYGEN (CD)’ ‘OXYGEN (CD) re-fill’

How did we plan our process change? 8. Create ward stock lists (BISSUE lists). The agreed stock holding was added to each ward stock lists under 2 new sections ‘medical gas rental’ & ‘medical gas re-fill’ Maximum values were added to the rental section which reflected the agreed number of cylinders each ward was to keep.

How did we plan our process change? 9. Engagement of the portering team Establish good working relationship with portering staff to ensure timely and accurate usage figures. Which wards have had which cylinders delivered to them? Which empty cylinders need replacing? Which cylinders are we running low on or are we overstocked on? Which wards are asking for cylinders that are not on their approved stock list?

How does our process work? We obtain twice weekly ‘re-fill’ orders from Facilities dept. Raise & send re-fill purchase orders to BOC twice a week. Validate each BOC re-fill delivery against purchase order and receipt delivery onto JAC We obtain weekly ward use figures from portering team and charge wards for re-fills Validate stock holding against BOC monthly rental charge and raise monthly rental purchase order. Receipt monthly rental purchase order and charge wards (issue stock).

1. Obtain twice weekly re-fill order from Facilities staff On a Monday and Thursday, facilities staff will inspect the cylinder stores and manifold rooms and advise us of any cylinders that need replacing (on a full for empty basis).

2. Raise & Send twice weekly purchase orders to BOC for ‘re-fill’ of cylinders. Based on the figures supplied to us by facilities, Pharmacy generate a purchase order on JAC and send to BOC via electronic fax (Powergate) Powergate allows us to specify ship-to account and enter any specific delivery instructions.

3. Validate BOC delivery against re-fill purchase order and receipt delivery on JAC In order to accurately manage stock it is important that each BOC re-fill delivery note is checked against its purchase order. If the delivery is short, we amend our purchase order to reflect this. In this way we maintain accuracy of stock holding and parity with BOC figures. We then receipt the delivery onto JAC (ODELIV). Pharmacy also use the BOC delivery note to keep a ‘leger’ of cylinders on site. This is used when validating BOC monthly rental charge.

4. We obtain weekly usage figures from Porters and charge wards for re-fills. Portering staff maintain a central record of the cylinders they have been asked to supply to wards and departments. At the beginning of each week, Pharmacy are sent a summary of wards and the cylinders that have been exchanged by porters. This information is used to charge wards (using JAC BISSUE program)

5. Validate stock holding against monthly rental charge & raise Purchase order A monthly cylinder rental invoice will be received from BOC. This is checked for accuracy against our cylinder ‘leger’ and any inaccuracies reported back to BOC. Once validated, a Purchase order is raised on JAC to cover the cylinder rentals.

6. Receipt monthly rental purchase order and charge wards (issue stock). The purchase order for monthly rental charges is receipted onto JAC using the ODELIV program and rental charges (based on each wards agreed stock holding) are issued to wards using the BISSUE program. Excess or ‘working stock’ (is charged to an agreed cost centre (in our case ‘gas store’ ) the charge for these cylinders is apportioned by finance based on the number of beds a ward has and the speciality of the ward, with high use wards being charged proportionally more.

Housekeeping – ensuring the processes and standards are maintained Ward ‘audits’ Identifying redundant (excess) stock Reporting (spend v’s budget)

1. Ward ‘audits’ Pharmacy undertake twice yearly ‘audits’ with a nominated ‘senior nurse’ and representative from facilities. Wards are visited and their cylinder requirements are reviewed as well as storage issues and signage being addressed. Audits can be used as an educational tool to re-emphasises to ward staff the importance of correct management of medical gases and maintain their engagement in the process.

2. Identifying redundant (excess stock) By capturing real usage data on JAC, we can identify genuine demand for certain medical gases. We can also compare average monthly use against current stock holding to highlight redundant stock. Redundant stock can be returned to BOC and rental charges reduced accordingly.

3. Reporting (actual spend v’s budget) By being able to reduce rental charges as a result of reducing stock holding, we can demonstrate genuine savings against budget. This makes us feel good  ….and can be used in part to demonstrate that our processes are working.

Thank you. Any questions?