Accidental Discharge of the Fire Sprinkler System in a Level I Trauma Center Operating Room

Abstract

BACKGROUND A fire sprinkler head activation occurred during cleaning being performed by environmental services (EVS) in an operating room (OR) suite of a 27 bed OR in a Level I Trauma Center. New fire pumps had recently been installed on the sprinkler system resulting in a reported 30,000 gallons of water discharged into the OR with multiple known areas of encapsulated mold from prior water intrusion. Remediation occurred while minimizing the impact on patient care, maintaining patient safety, isolating half of the OR's under negative airflow and performing air samples for clearance to return to full functionality, and following patients who were undergoing procedures in other ORs for any negative outcomes associated with this water intrusion. METHODS Extraction of water began immediately to areas both horizontal and vertical to the original OR. Removal of equipment and supplies had to occur for the evaluation of any potential contamination. All contaminated, disposable supplies were discarded and all exposed reusable trays were reprocessed by in-house sterile instrument processing department (SPD). The area impacted had to be isolated with poly wall barriers and placed under negative airflow. Specific attention was paid to those areas that had known encapsulated mold, requiring additional barriers and negative airflow. Remediation occurred and air samples were monitored during a six day period. Patients undergoing procedures were monitored for any fungal or bacterial infections. RESULTS Our impacted OR area was segregated off from the remaining OR's restricting the use of approximately half of our OR suites. Cases were able to be rescheduled with none of the patients undergoing procedures at the time of the event have developed any known procedure related adverse events. CONCLUSIONS With quick intervention and actions all water and mold remediation was completed in a timely fashion, with no negative outcomes for patients.