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Maintenance

How long do we need to keep maintenance logs/records/annual preventative maintenance records? We have kept records since we opened in 1998.
Published: 06 August 2015

How long do we need to keep maintenance logs/records/annual preventative maintenance records? We have kept records since we opened in 1998.

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

The answer to your question may be varied, and we suggest that you work closely with your Authority having Jurisdiction (AHJ) and internal resources available in your facility to make this determination. These may include facility administration, Quality Control, Risk Management, Safety, Information Management, compliance and clinical engineering departments. The National Fire Protection Association glossary of terms defines the AHJ as “An organization, office, or individual responsible for enforcing the requirements of a code, or for approving equipment, materials, an installation, or a procedure.” There is more than one AHJ that would have interest in the records kept. Examples of possible AHJs would include: NFPA, ASME (PVHO-1 and PVHO-2), UHMS, FDA, TJC, OSHA, CMS, State specific Department of Health, Local Fire Authority, Interest specific Insurance Carriers/Underwriters, and institutionally imposed standards.

It is important to know that many standards only have the force of law if recognized by a governmental agency with authority in your area. The others are only enforceable if agreed to by the institution, for example insurance carrier/underwriter rules.

There are valid legal reasons for and against maintaining records beyond 7 years. Legal liability for keeping records past a determined time should be discussed with those responsible for the risk management of your facility. The Joint Commission has typically asked for preventive maintenance history and service history up to 3 years, while other regulatory agencies may go back a little further in time. Other areas (such as pediatric, neonatal, labor and delivery, or maternity) expect records to be kept for 21 years. And in some cases, facilities will retain records indefinitely.

The code references listed below reflect several examples of specific regulations regarding record retention:

• ASME PVHO-2-2016, Section 1 General, 1-4 PVHO and PVHO systems documentation, “The owner shall be responsible for maintaining the following documentation for the service life of the PVHO and PVHO systems:
(a) documentation required by ASME PVHO-1, section 1, General Requirements
(b) documentation generated during inspection, maintenance, repairs, and modifications
(c) documentation related to operational procedures and manuals”

• NFPA-25, 2017 ed. 4.3.4 “As-built system installation drawings, hydraulic calculations, original acceptance test records, and device manufacturer's data sheets shall be retained for the life of the system.”

• NFPA-25 2017 ed. 4.3.5 “Subsequent records shall be retained for a period of 1 year after the next inspection, test, or maintenance of that type required by the standard.”

The reference document listed below may be beneficial in determining your needs, and is intended for information purposes only:

ACEC Risk Management Committee and NSPE Professional Liability Committee, “DOCUMENT RETENTION GUIDELINES,” 2016

Respectfully,

The UHMS Safety Committee

DISCLAIMER
Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet. If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, who can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility. Information provided on this forum is for general educational purposes only. It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

When we started our Wound and Hyperbaric Oxygen Unit about 6 years ago, we did this with the help of a consultant. One of the things that they were emphatic about was NOT to ever wax the floor of the hyperbaric unit. Unfortunately the cleaning staff waxed it this past weekend, and there is quite an odor in the unit. We have cancelled the dives for today, but we don't know what we should do next. Should we have the floors stripped and if so, when can we resume dives. Please help us figure out what to
Published: 14 January 2018

When we started our Wound and Hyperbaric Oxygen Unit about 6 years ago, we did this with the help of a consultant. One of the things that they were emphatic about was NOT to ever wax the floor of the hyperbaric unit. Unfortunately the cleaning staff waxed it this past weekend, and there is quite an odor in the unit. We have cancelled the dives for today, but we don't know what we should do next. Should we have the floors stripped and if so, when can we resume dives. Please help us figure out what to

Thank you for your question. The UHMS hyperbaric oxygen safety committee (SC) can provide information but the ultimate responsibility for these types of questions is with the medical director and safety director of your facility.

Regarding: Waxing the floor of a monoplace suite

You did the right thing in canceling the treatments until the odor dissipated. The odor in and of itself may be a health and safety concern. The issue of waxed floors in the monoplace suite has been a topic in the hyperbaric community for quite some time. We can state with confidence, that there are many monoplace suites over many decades that have waxed floors in the room housing the class B chamber(s).  There have been no reported incidents due to waxing of the floors in the monoplace room. The chamber manufactures have been asked to remove this language from the manuals, but there are still some that include …“no wax or terrazzo flooring, carpeting is not allowed”. This stems from a concern about static electricity building up and becoming a possible ignition source. While carpeting should not be allowed, the no wax or terrazzo flooring prohibition has been shown to be unnecessary. More importantly it is required that both the monoplace chamber and patient are grounded. Neither the NFPA 99, 2018 edition, chapter 14, or the UHMS Hyperbaric Facility Accreditation Program prohibit waxed floors in the monoplace suite.

Normally we would direct you to the chamber manufacturer for guidance. In this case we would encourage you to work with your facility environmental services and care for the flooring as per the hospitals policy and procedure. There are positive aesthetic and infection control reasons to wax the floor. Since we do not know the type of flooring in your facility, the wax may indeed need to be removed. This will depend on the type of flooring your facility has installed. Work with your facility’s engineers and the environmental services and document your findings.

  • Caution must be used to insure that none of the flooring product (either the wax or the wax remover) be allowed to get on the acrylic window of the chamber. This may damage or red tag the acrylic. Since you were not engaged in this incident until after the fact, we would encourage a complete, documented, maintenance inspection of the acrylic per ASME PVHO-2 to insure that no damage has occurred. If damage has occurred, you may need to replace the acrylic window.
  • Housekeeping must be trained in the hazards of hyperbaric medicine and this training needs to be documented.
  • Continued communication with the environmental services so that any maintenance of the flooring be done in a scheduled and coordinated manner.

DISCLAIMER
Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.