Maintaining Patient Safety During a Water Intrusion in the OR


Health workers had to act quickly when 30,000 gallons of water spilled into the operating room of a level 1 trauma center in Texas.

Operating rooms should remain disinfected and sterilized at all times, but health workers had to act quickly when 30,000 gallons of water spilled into the OR of a level 1 trauma center at the Baylor Scott & White Medical Center in Temple, Texas.

Care providers were able to maintain operations and patient health and presented how they did so after the spill, which occurred during cleaning being performed by environmental services. The details of the situation response were presented in an oral abstract session at the Association for Professionals in infection Control and Epidemiology’s annual conference (APIC 2019).

During routine cleaning by the environmental services department, a fire sprinkler head was activated. New fire pumps had recently been installed on the sprinkler system and dumped 30,000 gallons into the OR, which had several previously known areas of encapsulated mold.

Response teams began extracting water immediately and removed all equipment and supplies for evaluation of potential contamination. All products that were found to be contaminated that were disposable were discarded and reusable items underwent sterilization processes.

The impacted area, which comprised about half of the OR, was separated from the unimpacted area with poly wall barriers and placed under negative airflow. The investigators note that special attention was given to the areas with previous mold exposure, which required additional barriers and negative airflow.

Although remediation occurred, the health workers prioritized minimizing the impact of the incident on patient care while maintaining patient safety and monitoring the environment. Air samples were monitored during a 6-day period and patients who were undergoing procedures were closely monitored for any negative outcomes such as fungal or bacterial infections.

The investigators report that none of the patients undergoing procedures when the water was discharged developed any known related adverse events.

The investigators conclude that, “with quick intervention and actions all water and mold remediation was completed in a timely fashion with no negative outcomes for patients.”

Findings from the study, “Accidental Discharge of the Fire Sprinkler System in a Level 1 Trauma Center Operating Room (ECR-13),” were presented on Friday, June 14, 2019, at APIC 2019 in Philadelphia, Pennsylvania.

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