Wesson Building Medical Air Compressor Failure, Replacement, and Next Steps Emily Bonazelli Clinical Engineer

Overview Wesson Building One Medical Air Compressor Neurology and Sleep Center Wound Care Hyperbaric Medicine Labor and Delivery NICU One Medical Air Compressor

Medical Air Compressor Failure Event Saturday, January 28, 2017 7:45 PM Engineering made aware of no pressure alarms on the medical air compressor Low air pressure alarms on 6 ventilators in NICU All air/oxygen blenders alarm loss of air (<20 psi) NICU called security and CE on-Call

Medical Air Compressor Failure Event Saturday, January 28, 2017 8:30PM Engineering discovers the source of the leak and restores system pressure Ventilators reestablish air pressure CE on-call arrives at the Wesson Building CE on-call reaches out to Supervisors CE Supervisors reaches out to CE Respiratory specialist CE Supervisor reaches out to Respiratory Manager to identify possible air tanks and regulators

Medical Air Compressor Failure Event Saturday, January 28, 2017 9:30PM CE Supervisor and CE Respiratory Specialist arrive on scene CE and NICU staff begin disconnecting all ventilators and blenders not in use to help relieve stress on compressor Medical Air Compressor Vendor arrive on site 10:15PM CE discuss medical air compressor with Engineering CE reconnects ventilators and blenders to test compressor 11:30 PM CE checks with clinical staff before heading home

Root Cause Analysis (RCA) Timeline Leading up to the Event Project Title: Wesson Women and North Wing Medical Air System Date: 01/28/2017 Event Description On Saturday January 28th, 2017 at 7:51 PM the NICU staff observed a system air pressure alarm. Six ventilators alarmed indicating ‘Low Pressure’ and all air/oxygen blenders alarmed indicating a loss of air pressure at least 20psi less than oxygen. It was determined that there was a loss of medical air to the Wesson Women and North Wing buildings. Timeline Leading up to the Event Date 01/28/2017 Sequence of Events There was an air leak in tubing connecting the compressor to the pressure gauge The pressure gauge indicated that there was no pressure in the pump causing the system to over pressurize one compressor The pressure gauge continued to read zero pressure in the system causing the system to turn on all three compressors All three compressors over pressurized causing all three safety values to open in order to reduce pressure resulting in a massive air leak The air leak caused an actual loss of pressure in the system The loss of pressure caused the system to no longer deliver air to the air outlets throughout the Wesson Women and North Wing buildings Investigative Team Engineering Clinical Engineering

Replacement Planning Monday, January 30, 2017 – Thursday, February 2, 2017 Engineering, CE, and Clinical Staff worked to determine the following: Shutdown time frame NICU evacuation site Amount of medical air tanks needed to sustain NICU, LDRP, and Hyperbaric through the shutdown

Replacement Planning Shutdown time frame NICU evacuation site Tuesday, February 7th at 9 am Will take about 8 hours NICU evacuation site Dedicated four rooms on Infants and Children's unit Amount of medical air tanks needed to sustain NICU, LDRP, and Hyperbaric through the shutdown Medical air tanks were ordered to set up a tank farm to back fill medical air Location of tank farm

Replacement Planning Monday, February 6, 2017 CE and Clinical staff rounded in NICU to determine how many patients are on blenders and vents CE set up four rooms on Infants and Children’s including NICU code cart Engineering set up tank farm Hard stops included: baby needing or on an oscillator

Replacement Tuesday, February 7, 2017 7:30 AM 8:00 AM 9:00 AM 2:13 PM CE and Clinical staff rounded in NICU to determine how many patients are on blenders and vents 8:00 AM Emergency operations center opened 9:00 AM Shut down begins Running of tank farm 2:13 PM Switched to secondary tank farm 3:30 PM Medical Air Compressor replacement installed and functioning

Replacement Pressure checks every 2 hours Every step was communicated to the EOC

Concerns with Current State Wesson Building usage of Medical Air >6000 hours of runtime for all three compressors in 2 years HOF medical air compressor has a runtime of 500 hours in 6 years Replaced Medical Air Compressor with same model Needed a high pressure line for hyperbaric chamber Know single point of failure

Medical Air Usage Hyperbaric chambers were replaced and no longer needed a high pressure line 1 blender at every bedside in NICU 1-2 blenders in every LDRP room Blenders remain on at all times

Next Steps Continue to discuss blender usage in the Wesson building Add a second Triplex compressor Requires second medical air shutdown Currently scheduled for the end of April

Questions?