Rounding, Nov/Dec 2018

How did your team adapt to a recent loss of safe drinking water? What lessons did your team take away from the shortage?

St. David's HealthCare, Austin
Ken Mitchell
Ken Mitchell, M.D.
Chief Medical Officer

In response to the recent flooding in Central Texas, the City of Austin implemented a boil water notice in the early morning hours of Oct. 22. We were notified by the Capital Area Trauma Regional Advisory Council Emergency Operations Center of the impending boil water notice around 10:45 p.m. Sunday, Oct. 21. We held a series of emergency management planning calls with leaders from across our health care system throughout the night to ensure plans were in place to mitigate clinical impact.

Our immediate concerns were how to supplement the emergency supply of water on hand at our hospitals, whether or not we should delay surgeries and procedures scheduled for early Monday morning, how the boil water notice would affect infection prevention procedures throughout the hospitals and surgery centers, and to ensure the food service staff was ready to serve breakfast using consumable water.

Each hospital is required to have a 96-hour supply of water on hand. Fortunately, securing adequate supplies of supplemental water for our impacted facilities was not our greatest challenge during the weeklong water boil notice. In addition to bottled water, six water tanker trucks with consumable water were secured from across the state and stationed at impacted facilities.

Working through implications of the water boil notice on all infection prevention processes and procedures was one of the most challenging aspects of the incident. Everything from public drinking fountains, ice machines, hand hygiene, patient bathing, hand scrubs for sterile procedures, hemodialysis, instrument decontamination and high-level disinfection had to be evaluated. We implemented approved waterless hand scrubs for surgery and sterile procedures, and we also outlined the process for securing a clean water source for pre-cleaning of scopes/probes.

By day three, we turned our focus to remediation and what would be required to bring operations back online once the boil water notice was lifted seven days later. St. David’s HealthCare followed Centers for Disease Control and Prevention guidance and consulted with infection prevention leaders, water remediation experts and experienced facility operations leaders before resuming all normal operations.

Throughout this process, we learned that the use of our incident command notification system was highly effective in coordinating our response at the facility level and systemwide. However, we found that guidance during a water event of this magnitude and duration is not as readily available as one would hope. Fortunately, we were able to draw upon excellent infection prevention guidance from our partner, HCA Healthcare. The CDC also provides very clear guidance on some processes, including the provision of hemodialysis during a water boil notice. In the future, we might also consider investigating additional plumbing connections to allow direct connection to the water tankers, as well as mobile reverse osmosis systems.

Thankfully, our patients and medical staff were extremely supportive and understanding, and our amazing caregivers provide exceptional care throughout the incident with no adverse outcomes.

Childress Regional Medical Center
Holly Holcomb
Holly Holcomb
Chief Operating Officer

As a hospital, we had lightly discussed that our community’s public water infrastructure was aging. Light discussion leads to only light planning. On Thursday, Oct. 4, 2018, Childress experienced a water main break. CRMC lost the public water source to our campus for 27 hours followed by a 24-hour mandatory boil notice. CRMC was not adequately prepared for that 51-hour outage.

The incident gave us a number of lessons learned and advice we’d pass along for other hospital leaders. First — and maybe most importantly — the loss of public water source is both an internal and external disaster so you should activate your facility’s disaster plan early. Initiate and utilize incident command. Communicate event details and plans with staff and physicians early and often. Designate a person to send out timely update emails. Have a face-to-face meeting with your department leaders. This usually happens when open incident command. Our county had informational meetings at 11 a.m. and 2 p.m. for updates, planning and shared resources.

Think about water going in: Talk with your dietary department early to get a count of bottled drinking water on hand. You should have at least 72 hours’ worth stored at a rate of three gallons per patient per day and one gallon per staff per day. Assign staff members to distribute cases of bottled water to departments and monitor every four to five hours for restocking needs.

And plan for water going out: Our hospital has pressure valve toilets. Without water pressure, the toilets throughout the facility would not flush. They are not like residential toilets where you can manually pour water into the bowl to trigger a flush. Toileting was our biggest issue early on in the situation. We ordered four port-a-potties (three regular and one with handicapped access) from a private vendor 60 miles away. They were on campus within about four hours. In the meantime, our inpatients utilized bedside commodes.

We had to take stock of any changes in our overall capabilities. Nursing Management, UR and attending physicians reviewed inpatient census. Patients who could safely be discharged to home or nursing homes were ordered as such. Early in the event, we reviewed the surgery schedule. We canceled all elective surgeries for 24 hours initially then extended that to 48 hours. We set up for an emergency C-section and the team had discussed a waterless scrub. No water equals no dialysis treatments, so we made arrangements for our 17 dialysis patients to travel 100 miles to receive their life-sustaining hemodialysis treatments in Amarillo.

We had to embrace some unknowns. We had a new water softener system. Our plant manager called the water softener installation contact to ask if we should turn the system off due to low pressure. The vendor said it wouldn’t be a problem because the unit should register the low pressure and auto bypass. Unfortunately, the low, fluctuating water pressure created a suction that collapsed one of the water softener tanks. $7,000 to replace the damaged tank later, the lesson learned is that if we have low pressure water issues, we will bypass the water softener system to prevent damage to the unit.

The RAC delivered and set up a FirstWater portable water purification system outside of CRMC emergency room. It was a game changer. The portable RO system was the turning point that allowed us to confidently say “Yes —we’ve got this.”

One of our biggest takeaways from the event is the need to find the humor to create unity. CRMC staff and the Childress community as a whole came together during this disaster. Humor was a good outlet and bonding material. A smile and a laugh are invaluable during stressful times. CRMC could not be prouder of our people. They handled the water outage like champs. The CRMC staff verbalized many times that their main goal was to be a stable and available resource for the Childress community during the disaster event. Goal met!