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Pipes at VGH burst, sending dirty water into operating rooms while patients had surgery

A full complement of 18 to 20 operating rooms at Vancouver General Hospital will finally be back in use Thursday after a burst water sprinkler pipe caused unsterile water to leak into multiple operating rooms through lights and air vents while surgeries were taking place.

Postmedia has learned that midway through long, complex cancer and other urgent surgeries on Oct. 30, medical teams noticed water dripping from a handful of operating room (OR) ceilings, potentially compromising the safety of patients undergoing surgery. Operations in progress were completed, but half the ORs were then closed, resulting in the cancellation and rescheduling of nearly 100 urgent and lifesaving cases.

Hospital officials confirmed the crisis Wednesday.

A mishap during construction work on the third floor of the hospital was what led to the burst pipe, causing water to leak through a mechanical subfloor just above all the ORs on the second floor of the Jim Pattison Pavilion. The water then dripped through light and ventilation shafts into the ORs, but fortuitously, not directly onto anesthetized patients undergoing surgery.

It was 11 a.m. and several operations — some of them five hours in duration and longer — were in progress, with numerous patients in the holding area. Surgeons and infection control experts made immediate assessments on whether it was safe to continue the operations. In one case, a surgeon decided it was not safe to continue working in the leaking OR, so the patient on the table was temporarily closed up with sutures and the medical team moved the patient to an adjacent room where the all-day operation resumed.

One cardiac case that was in a critical stage proceeded in the leaking room as hospital staff sealed off the sterile area with plastic.

Dr. Marcel Dvorak, a spinal surgeon who is associate medical director at Vancouver Coastal Health, said multiple ORs had “active water” dripping into the peripheral areas of the ORs. Nurses and other hospital staff “flew into action” using blankets to soak up water on the floors and suctioning water off equipment and surfaces. Tens of millions of dollars worth of electronic and sterile surgical equipment had to be protected and sealed with plastic.

In the 10 days since the leak, dehumidifiers have been drying out the moisture and new drywall has been installed.

There were no “untoward” incidents involving patients developing infections or other surgical complications as a result of the mishap, according to hospital administrators. The event was disclosed to all patients effected.

In one OR, the operation continued without incident for a number of hours, and in another, a patient was moved while under anesthetic “because it was deemed to be the safest thing to do.” Several rooms were considered “mechanically safe” with electrical and humidity systems intact so operations in progress were completed, but 13 other cases that were scheduled for that day were cancelled, Dvorak said.

“All emergency cases, like trauma, were managed, and that’s saying a lot because 60 per cent of our cases are emergencies — like transplants, ruptured aneurysms, cardiac emergencies, spinal cord injuries, etc., which means they are unscheduled,” he said.

The construction work going on the floor above the operating rooms is a $102-million OR expansion that will see 16 new ORs open in 2021.

VGH does about 16,800 surgical cases a year and with the addition of 16 more, capacity will increase to about 19,000 cases per year. Typically surgeries that take place at VGH are complex cases, while UBC Hospital shoulders the “more predictable” day surgeries.

“VGH treats the sickest of the sick from all over the province,” Dvorak said.

The existing ORs at VGH are 30 years old and considered too small for many types of cases requiring big medical teams, robotics and imaging equipment. Eventually, the existing ORs could be decommissioned or replaced. Dvorak said the OR expansion is “on time and on budget.”

He said anyone who has ever done renovations knows they can expect problems of some sort. “This was an out of the blue incident.”


Andrea Bisaillon is VGH’s operations director for surgeries.

Arlen Redekop /

PNG

Andrea Bisaillon, an operations director at VGH, said: “The exact details of who did what is now being investigated. Our first priority was focusing on keeping patients and staff safe.”

She said PCL is the overall contractor for the construction project. The restoration company that has been retained for the salvage effort is called Proactive and “they are extremely aware of the fact that our first priority is the safety and lives of our patients.”

Dvorak said emergency preparedness exercises that hospital staff undergo to prepare for natural disasters such as earthquakes or other crises proved their worth.

“Simulation exercises that we do to learn how to handle mass casualties and other critical incidents help us prepare for these kinds of scenarios.”

Carrie Stefanson, a spokeswoman for the hospital and health authority, praised the efforts of hospital staff, both during and after the crisis.

During a week of repairs and remediation, VGH has continued to meet the needs for emergent, urgent and transplant surgeries, including a cardiac diversion case from Royal Columbian Hospital.”

The leak issues at VGH evoke a similar — if not more serious — crisis at Surrey Memorial Hospital six years ago when contractors broke a water main causing knee-deep flooding in the emergency department and other areas.

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Twitter: @MedicineMatters




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