Although hospital managers knew the technology had been used extremely effectively in other US buildings, this was reportedly among the first ever healthcare applications.
Officials at the Oxnard hospital facility, where I was working at the time, decided on the fumigation process in place of the traditional “rip and tear” method, where drywall is removed, the underlying surfaces cleaned with a solution to kill any remaining mould, and the area re-built, after hearing a CNN report that described how some facilities in the south of America had dealt with mould post-Hurricane Katrina. New Yorkbased Sabre Technical Services, which contracted to undertake the fumigation, had experience fumigating using chlorine dioxide to fight anthrax in government office buildings, and had also fumigated several facilities in the New Orleans area, including restaurants, homes, and businesses, for mould-related issues. While using the more “traditional” method would have entailed a complex project lasting another 5 to 6 years, the fumigation process allowed our team at St John’s to limit the corrective construction to under a single year, thus saving costs and time and, more importantly, keeping more hospital beds in service for the community. The process involved “tenting” the entire facility, and very substantially raising both the relative humidity level and temperature levels. As the hospital’s existing HVAC systems did not provide this level of humidification, other means of introducing it – namely three large steam generators – had to be employed. The chlorine dioxide gas was introduced throughout the facility using the existing HVAC systems, with several monitoring points established to verify that the humidity, temperature, and gas concentration levels were all at the correct levels to ensure an effective “kill” of the mould.
‘Thinking the unthinkable’
The fumigation process required us at St John’s to “think the unthinkable” – to voluntarily shut down the hospital and transfer all of the patients out of the facility. The undertaking was monumental, to say the least, as St John’s is the largest hospital in Ventura County. Several working groups were established to make sure the process worked as planned. Firstly, an executive steering committee was formed to guide the overall process. Secondly, a CEO/COO/CNE workgroup from all of the hospitals in the local area was established to help communicate information from one facility to another. Other workgroups were established for specific functions, including patient care; logistics; security; emergency medical services (EMS); communications, human resources, spiritual care, and governmental relations.
Workgroups established
The workgroups had to develop plans to decide on the best time to shut down the hospital from a patient volume perspective – not just as far as St John’s, but rather as far as the whole community was concerned, what to do with employees who would not have their traditional job to do during the fumigation, what equipment and supplies should be removed during the process, and how to secure the facility in terms of trying to access it for medical care from entering. The work plan called for the facility to fumigate on a particular summer weekend, with the actual introduction of the gas into the building due to start at 8:00 p.m. on the Friday concerned. The plan was for a period of 12 to 13 hours of fumigation, followed by an approximate five-hour “scrubbing” period to remove the chlorine dioxide gas from the facility. Once these timeframes were established, the patient care/logistics workgroups started calculating the amount of time they would need to make sure all patients could be safely and effectively removed from the facility, while: a) still providing medical care for the maximum amount of time, b) keeping the facility closed the least amount of time (including keeping the Medical Office Building open at all times except on the weekend of the actual fumigation), c) being able to remove equipment and supplies before the fumigation, and d) returning the equipment and supplies after the fumigation. The dates were then set as follows:
• To close the emergency department on 8 August at 7.00 am (no new admissions to the hospital).
• To close the inpatient services on 14 August at 12.00 pm.
• To remove equipment and supplies from 14-17 August.
• To close the Medical Office Building at 7.00 pm on Friday 17 August.
• Fumigate the weekend of 17-19 August.
• Re-open the Medical Office Building at 6.00 am on 20 August.
• Re-equip and re-supply the hospital starting at 7.00 am on 20 August.
• Department of Health Services to evaluate the hospital for re-opening at 3:00 pm on Thursday 23 August.
• Re-open the emergency department and the rest of the hospital at 7.00 am on 24 August.
Start ‘on schedule’
The process started out as planned, with the Emergency Department closing right on schedule. The inpatient services closed a day sooner than scheduled. Equipment and supplies were removed on schedule. The fumigation did not start as scheduled due to mechanical issues with the humidification. The fumigation actually started in the early morning hours of 19 August, and was completed around midnight that same day. The “scrubbing” cycle lasted until about 4.00 am on Monday 20 August and the Medical Office Building opened as scheduled at 6.00 am. The monitoring equipment and tent were removed during the day. The equipment and supplies were reintroduced into the facility at around 6.00 pm, almost 11 hours behind schedule. Fortunately, the hospital was able to be reequipped and re-stocked for the Department of Health Services inspection on Thursday 23 August and the hospital resumed full operations, the following day at 7.00 am, as planned. Believed to be the first hospital to utilise the chlorine dioxide technology for mould remediation, the project allowed St John’s Regional Medical Center to effectively shorten the project timeline by almost five years. The project in more detail Describing to HEJ in a little more detail how, working with fumigation specialists Sabre Technical Services, the St John’s Regional Medical Center prepared for, and undertook, the fumigation process, Robert Hacker (who is now regional director for Facility & Construction Services at Providence Health and Services) admitted it had been “an interesting experience but not one I’d necessarily ever want to go through again”. He went on to explain some of the key steps undertaken as part of a carefully conceived plan to vacate all the patient areas, including arranging the transfer of a number of patients to other hospitals, tenting much of the 400,000 ft2 campus, fumigating the medical and clinical areas, and subsequently moving the patients, equipment, and staff, back in. “While the company that undertook the fumigation for us, New York-based Sabre Technical Services, had extensive experience of fumigating premises such as Government buildings, especially following the anthrax scares early in the Millennium, and had also worked in residential, office, and industrial facilities following Hurricane Katrina, this was the firm’s first ever project of this magnitude in a healthcare setting,” he explained. “Indeed we believe this may have been the world’s first ever use of fumigation to deal with mould in a hospital on such a scale, so, despite Sabre’s considerable experience, expertise, and track record, we were all working in somewhat uncharted territory.”
Poor window seals
Robert Hacker explained that mould was first discovered within the wall cavity in some of the patient wards during refurbishment work. “It was clear that there were two principal sources of the damp that was causing it,” he explained. “The first was that the windows in some parts of the hospital had poor window seals. We also found mould in some showers in the patient areas, and, although our initial investigation covered only a limited area, it soon became clear that mould was present through the walls of much of the main medical buildings. “Normally,” he continued, “standard practice would have been to use the ‘rip and tear’ method to pull away internal drywall plasterboard, use a solution of 10% bleach to kill the mould, and subsequently fit new drywall, and indeed we began by deploying this approach. However it rapidly became clear that treating all the affected areas this way would have taken 4-5 years, entailing substantial cost, and causing significant disruption to both patient care and clinical activities. “We actually chanced upon fumigation almost by accident,” he added. “Our CEO, Michael Murray, came to me one morning, having heard a CNN news report about how fumigation had been successfully used in facilities including food production plants, offices, and residential buildings, in the south of the US in the aftermath of Hurricane Katrina, and suggested that we contact the company involved, Sabre Technical Services, which subsequently sent out a team of around 40 personnel to undertake the job.” Before the process could start, however, Robert Hacker and the various workgroups at the hospital had to decide how best to accommodate patients while the fumigation was undertaken. He said: “St John’s is the area’s largest full service hospital, and our main priority was to ensure that disruption and inconvenience to local patients were minimised.”
Liaison with physicians
Among the strategies used to ensure this was close liaison with physicians serving the hospital (many of whom are not directly employed by it) so that important operations were not scheduled over the planned fumigation period, and with other local hospitals to which patients could be diverted. Liaison with the surgeons saw many either delay or speed up elective surgery, and many took their holidays in the run-up to, and during, the fumigation process. To effectively fumigate the medical buildings involved, Sabre had first to erect tarpaulin tenting over them, a considerable undertaking in itself. “Prior to this happening,” Robert Hacker explained, “we carried out extensive testing to see which equipment and hospital fittings we could safely leave inside, after which we removed everything else, which meant moving out a lot of electrical equipment and a substantial quantity of hospital furniture. We also had to remove all food supplies, which were then put into rented refrigerated lorries on the campus.” The team – the hospital’s estates and facilities team worked closely with Sabre throughout – then faced the challenge of creating the “right” conditions inside the buildings for the fumigation with chlorine dioxide gas – a potent killer – to take place. “Because the gas works optimally in destroying mould at higher temperatures and humidities we had to raise the buildings’ internal temperature to around 90°F (32°C) and relative humidity to around 80%,” Robert Hacker explained. “This was why we had to test equipment – to see if it could withstand such conditions – and then remove any that we judged would not be able to do so before the fumigation process could begin.” Having achieved the required environmental conditions and effectively created a sterile chamber within the buildings via the tenting, the estates team and Sabre then fed in the chlorine dioxide gas via the hospital’s air handling plant. As the facility was without the necessary humidification equipment to achieve the required humidity levels, the estates team had to hire three portable humidifiers, which then pumped in around 200 gallons of steam /hour until the correct level was achieved.
An ‘indiscriminate killer’
Robert Hacker said: “Sabre’s chlorine dioxide generators, which were connected to our air handling plant, use a proprietary process to generate the gas, which is pretty well an indiscriminate killer, and is thus extremely effective at dealing with mould.” After 13 hours of fumigation the air within the building was then carefully “scrubbed” to remove any gas, with both air intake and exhaust carefully controlled. Robert Hacker said: “Both immediately prior to, throughout, and following the fumigation process, a team of US Environmental Protection Agency inspectors very closely monitored air quality, and was on hand in the immediate aftermath to ensure we had effectively cleared the building of any traces of chlorine dioxide. We also used meters connected to a network of tubing so that, at any time, we could gauge the levels of gas present, and indeed sampling was undertaken almost constantly.” Robert Hacker says that, despite the enterprise’s scale, Sabre Technical Services proved well up to the task: “The Sabre team was extremely meticulous, and indeed the tenting process alone took four days. Their previous record – for instance the company fumigated the Hart Senate Building in Washington following the receipt by staff there of envelopes containing anthrax in 2001, and had also dealt with severe conditions following Hurricane Katrina – convinced us they had the skills and expertise for our project.” Following the air cleaning, or “scrubbing”, and the EPA’s confirmation that it was safe to move equipment and food back in, patients began being returned to the hospital, and the entire facility was re-opened on 24 August, just over two weeks after staff initiated the hospital’s closing when they shut the Emergency Department for new admissions on 8 August. Robert Hacker said: “A fumigation process of this type is undoubtedly quite expensive, but it has the major advantage that we could effectively clear the affected buildings of mould in reactively short timescale, rather than having to undertake the project piecemeal, with all the ensuing disruption to patients and staff, over a much longer period, that a longer remediation process would have entailed. The project was undoubtedly a success, but there is no question that taking out of service a hospital of the size of St John’s even for a two-week period is a pretty major challenge.”