Being prepared does not cover all eventualities

Dr. John Williams, David Carty and John McElhinney write about a previously unimagined eventuality in Sligo General Hospital which required quick thinking, planning and immediate crisis management to mitigate serious injury and loss of life at the hospital. 

Dr.John Williams, Pathology Department and David Carty and John McElhinney, Risk Management Department, Sligo Regional Hospital.
Dr. John Williams, Pathology Department and David Carty and John McElhinney, Risk Management Department, Sligo Regional Hospital.

Pathology is the study and diagnosis of disease through examination of cells, tissues, body fluids and organs and lies at the heart of the health care services provided to patients.  It is estimated that between 70 and 80 per cent of all health care decisions, affecting diagnosis or treatment, involve a pathology investigation.
In addition to its 24/7 work for emergency, inpatient, outpatient and day care services, the Pathology Department offers a comprehensive diagnostic service to local GP surgeries and private and community hospitals.

To function safely and efficiently an uninterrupted supply of electricity and clean water is essential for all pathology laboratories to provide the vital service for diagnosis, treatment and monitoring of newly admitted, critically ill and recovering patients.

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The following describes an incident, resulting in a total loss of electrical power, at tche Pathology Department of Sligo Regional Hospital which provides emergency, medical, surgical, paediatric, obstetric and ICU services, among others, to a wide region of the north west of Ireland. The population served by the hospital is approximately 285,000 people for all services, including some regional services.   On any one day, the hospital would have over 125 emergency presentations, along with an inpatient bed profile of 262 beds.

What actually happened in Sligo.

On October 26, 2012, during the cleaning of water tanks by external contractors, situated in the ceiling cavity above the Pathology Department, a water pump was accidentally disconnected. Water spilled into the ceiling cavity and thereafter onto the electrical power control boards situated on the wall directly below. This caused a loss of the electrical power supply to parts of the main biochemistry and haematology laboratories. This was immediately rectified by the on site maintenance team.

The population served by the hospital is approximately 285,000 people for all services, including some regional services

A further incident, leading to a total loss of electrical power, occurred during the night of Saturday October 27. An initial partial power outage occurred at 03.00 and was attributed to fuse blow out caused by residual water in the control boards from the previous day. The problem was addressed by the on call electricians and power was restored within two hours through the use of a bypass circuit. However, shortly afterwards, staff noticed a significant flow of water from the ceiling close to the location of a fuse box. Within minutes this fuse box “exploded” emitting black smoke, a trip switch device in another section’s fuse box was activated and the result was an immediate total loss of electrical power to the entire Pathology Department.

Consequently the hospital had no access to pathology based testing of any type resulting in a crisis not previously encountered or envisaged. Despite Department and hospital disaster plans being in place, this previously unimagined eventuality required quick thinking, planning and immediate crisis management to mitigate serious injury and loss of life at the hospital.

Actions

The Pathology Department Manager was contacted, advised there was a total power outage and flood in the department and asked to attend the hospital immediately. After a brief assessment of the problem; the Emergency Department (ED), Nursing Office and the Intensive Care Unit (ICU) were advised of the absence of pathology services. Thereafter, the situation was cascaded through the managerial structures: the Consultant Anaesthetist in charge of the ICU, Nursing Administration, the Hospital General and Assistant Managers, the Area Manager and other clinical areas. The Pathology Manager at Letterkenny General Hospital was contacted and agreement was secured to process urgent pathology samples from SRH until normal service could be restored.

Within two hours the electrical power supply was restored to one of the affected fuse boxes. However, this restored power to the histology and microbiology areas, with only partial power to the central reception area. Equipment in these areas was checked and deemed in good order. Some of the stocks, reagents and blood products, in warming fridges and freezers were moved to functioning powered units. This ensured blood and blood products were stored appropriately and that as much reagent stock as possible was salvaged.

Consequently the hospital had no access to pathology based testing of any type resulting in a crisis not previously encountered or envisaged

A crisis management meeting was arranged and attended by the General Manager, the duty Consultants in Medicine, Emergency Medicine, Anaesthetics, Paediatrics, Obstetrics, the Director of Nursing/Midwifery, maintenance department staff, the Pathology Manager, Senior Medical Scientist Blood Transfusion and the area Ambulance Controller to outline the position and formulate an indicative time for the return to full operations.

Immediate decisions were made as follows:

  • Blood Bank. It was agreed that un-crossmatched blood would be used in emergencies. A very limited capability to cross match blood remained available.
  • No haematology or coagulation services were available. It was agreed that coagulation analysers would be prioritised when a power supply was available.
  • No biochemistry service was available. It was agreed that Point of Care Testing (POCT) would cover Biochemistry in most cases but there were concerns related to obstetric cases, difficult Paediatric cases and emergency patients with diabetes, etc.

At this stage it was envisaged that within one to two hours power would be available to some extent and that the Haematology service would be restored provided there was no permanent damage to instrumentation. The maintenance team was confident that full power would be restored within twelve hours.

Further discussions focused on the needs of the patient population on site: potential ambulance transfers were evaluated and the Internal Incident Plan was activated.

A private ambulance was placed on standby and it was agreed that urgent samples for analysis would be transported to Letterkenny General Hospital by taxi at designated times. It was agreed that the situation should be reviewed hourly, with the Pathology Manager nominated to provide progress updates.

Within one hour of this crisis meeting the power supply was restored to the Haematology analysers using long extension leads. These analysers were assessed as functional and therefore the necessity to taxi samples to the other facility for Haematology analysis ceased.

Throughout this time electricians worked on the burnt out fuse board. The required replacement parts were secured from a number of local suppliers to facilitate the repair. The plumber had difficulty finding the leak but expressed the view that this power outage was not related to the one the previous day but came from a primary leak source.

A mobile blood bank was established in the nearby staff room

Blood samples for Biochemical analysis were sent to the Letterkenny General Hospital Pathology Department at 13.00hr and 16.00hr, as previously agreed, as electrical and water supply was still unavailable for the Biochemistry laboratory at SRH.

Seven hours after the initial crisis meeting the power supply was completely restored by the electricians; the leak was located at the pipe supplying water to the Biochemistry water purification system and repaired. This ensured that all analysers were functional and online by approximately 19.00hr, the latter requiring the assistance of the Laboratory Information System manager.

Aftermath

The situation on the following day (Sunday) was unremarkable. However there was a further power outage on the following Tuesday morning at 09.15 which was identified as being related to the previous issues. Power was restored within one hour and no further outages were reported.

Findings and Recommendations

Causes

During the process of cleaning the main water tanks the disconnection of the water pump caused a water spillage which caused short circuiting of the electrical power supply to the Pathology Department. A second leak, the cause of the main power outage, remained undetected until it resulted in the incident outlined above.

Findings

  • The dependence of a critical area such as Pathology on one source of electricity highlights the vulnerability of such an arrangement.
  • The incident highlighted a lack of appropriate refrigeration space to store expensive reagents and blood products in the event of an emergency or a major incident.
  • The lack of any formal arrangement with external laboratories to accept work in an emergency situation creates confusion and potentially adds delay to an already precarious situation.

Recommendations

  1. In order to identify any potential risks associated with maintenance tasks to be undertaken (especially when using external contractors), it is recommended that a Plan of Work be produced before any work commences and discussed between the maintenance and service managers. Particular emphasis should be placed on the working environment and use of local knowledge is vitally important.
  2. All staff working in the Pathology Department, especially those working on call and out of hours, should be aware of the protocol for dealing with major internal incidents, in particular emergencies not previously envisaged. This should include clear instructions on who needs to be contacted (Communication Cascade).
  3. A business continuity plan is required by the Pathology Department which will provide clear guidance for staff in the event of an occurrence of an incident of this type. Consideration should be given to the priorities for service restoration, if the return of power is likely to be incremental. This plan should also include a formal arrangement with external laboratories to accept work from the facility in the event of a major event.

Conclusion

The power interruption that affected the whole of the Pathology Department highlighted the hospital’s dependence on a secure electrical power supply and the need for reliable backup systems. The overall management of this incident is to be commended and the teamwork approach, essential in a major incident, worked extremely well in circumstances not previously encountered or indeed planned for. In particular, the rapid response of the medical scientists “on call” averted much more serious effects on the quality and safety of patient care, financial consequences due to blood product loss, reagent and instrument deterioration and possible long term implications for service delivery.

Dr. John Williams, Pathology Department, Sligo Regional Hospital

David Carty and John McElhinney, Risk Management Department, Sligo Regional Hospital…