The Dorn VA Medical Center shut down its operating rooms Oct. 18 after a technician noticed unusual dust particles on supplies.
An investigation found problems with special filters in the air-filtration system. All operations since then — about 130 cases — were moved to nearby facilities outside the hospital for about seven weeks while the problem was fully investigated and fixed, hospital administrators said at a news conference Monday.
Dorn’s operating rooms are scheduled to reopen Dec. 2.
The hospital reviewed charts from 1,076 operations, dating back to July, to determine whether the dust had contributed to any medical problems. While there were six cases of hospital-acquired infections connected to the operating rooms during that period, the dust has been ruled out as a factor in those cases, said Ruth Mustard, associate director for patient care and nursing services.
Mustard also was unaware of any complications caused by moving surgeries, including 13 canceled on the day the dust was noticed, to other facilities.
The dust particles ended up in the operating room area because of the failure of a high-efficiency particulate absorption, or HEPA, filter. The specialized system that keeps the operating room area sterile has a bank of 15 large HEPA filters, which were maintained quarterly, according to James Cook, assistant chief engineer.
The dust was particles of a HEPA filter that disintegrated because of a problem with heating coils, Cook said. The filter manufacturer told the hospital this type of problem has never occurred before with their product.
The hospitals hasn’t determined how much the problem has cost, which would include the cost of repairs and the expense of the operations being performed in nongovernment facilities.
The hospital contracted with a duct cleaning company to clean all of the ducts and cleaned all surfaces in the operating rooms.
The operating rooms were scheduled to reopen Nov. 12, but more dust was found in a different area Nov. 6. That prompted another round of cleaning and repairs to the air-filtration system.
“The VA is a safe environment,” said David Omura, associate director of the hospital. “If something comes to our attention that needs to be corrected, we take steps to correct it immediately.”
Dorn has been under fire in recent months after the VA inspector general’s office found administrators had woefully understaffed its gastroenterology program from 2009-12. At one point, almost 4,000 patients recommended for gastroenterology tests were waiting to be examined, according to the report released in September.
The delays have been associated with at least 52 cancer cases and six deaths, and at least nine families have filed lawsuits about the delays, according to the report and later testimony before a U.S. House committee.
The report says steps finally were taken to resolve the backlog in consultations late in 2012, nearly three years after the concern first surfaced, in 2009.
The VA hasn’t publicly commented on that report other than to say steps have been taken to hire more staff in the gastroenterology department and the backlog has been eliminated.