Wesson Building Medical Air Compressor

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

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

3. 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

4. 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

5. 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

6. Root Cause Analysis

7. 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

8. Replacement Planning • Shutdown time frame • 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

9. 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

16. Replacement • Tuesday, February 7, 2017 • 7:30 AM • 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

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

18. 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

19. 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

20. 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

21. Questions?