Day 1, September 12, 2023

On day 1, there was a water main break in the city of Springfield Massachusetts for which the municipal water authority issued a boil water notice (BWN) to the entire city due to the potential of bacterial contamination of the water supply. The expectation was that the BWN would last for 48 hours.

Our facility, Baystate Medical Center (BMC), is a 746-bed urban academic medical center with a catchment area of 800,000 patients and the region’s only Level 1 Trauma Center. In response to the BWN, BMC established an emergency operation center and identified multiple areas in the hospital that used municipally supplied potable, non-sterile water. Various purposes of non-sterile water included handwashing and patient bathing, scrub sinks outside of operating rooms, dilution of cleaning solutions for daily cleaning of shared patient care equipment, ice machines for patient consumption and control of swelling, and eyewash stations.

Our initial response was to use 5-gallon jugs of water from a commercial vendor to aid in patient care activities. These 5-gallon jugs were obtained from the kitchen and food services department, which maintained a 96-hour supply for food preparation needs in case of emergency. We obtained spigots from local hardware stores to convert the jugs into dispensing stations to help facilitate handwashing and patient bathing. Because we repurposed the 5-gallon jugs from the kitchen to support patient care needs, we risked depleting the kitchen’s emergency supply.

Day 2, September 13, 2023

To maintain normal patient care activities without depleting the bottled water supply, the emergency operations team collaborated with the medical director of our dialysis unit to explore the feasibility of temporarily re-purposing portable reverse osmosis machines (ROM).

Our facility utilizes reverse osmosis (RO) to purify municipal water for dialysis sessions that occur outside of the dialysis unit as ROM successfully removes 99% of bacterial cells and endotoxins^{Reference Park and Hu1} in accordance with AAMI standards for water used in dialysis,^{Reference Pontoriero, Pozzoni, Andrulli and Locatelli2} which are stricter than water used as potable water.³ We have a fixed plant for our dialysis unit and portable machines for dialysis that occur outside of the dialysis unit. We perform monthly bacterial and endotoxin testing on our ROM to ensure these levels remain within acceptable AAMI range. In collaboration with the dialysis director, infection control, and clinical engineering, it was determined that ROMs could be deployed to treat the municipal water to provide the hospital’s patient care areas with purified water for hand washing, bathing, and other patient care activities outlined above. Both untreated municipal water and ROM-treated water were tested during this period, but the results were obtained 48 hours after the samples were collected and thus were not available before ROMs were deployed.

After accounting for the current inpatient hemodialysis needs and ensuring that the hemodialysis unit RO plant was functioning normally, we had 10 portable ROMs that could be re-deployed. We kept 2 in reserve and deployed 8 to patient care areas: the emergency department, the labor and delivery unit, 3 adult intensive care units, a medical inter-care floor, a medical/surgical floor, and the neonatal intensive care unit. These locations were selected with input from clinical engineering, the chief infection prevention officer, and a nurse director. This arrangement balanced the acuity of need along with geographic distribution across the various inpatient buildings of our hospital. Clinical engineering installed each portable RO unit via attachment to a faucet and plug insertion into a power outlet. The portable ROMs were used to refill water jugs, providing water for handwashing and patient bathing. Healthcare workers from neighboring units came to refill their jugs as needed if a ROM was not available on their unit. The deployment of these machines to strategic locations across the hospital to support refilling 5-gallon jugs for handwashing and patient care needs was cited by staff as extremely effective.

Day 3, September 14, 2023

The BWN was canceled on day 3; at this time, we believed we were well situated to continue our response for at least another 5 days without needing to curtail any patient care activities or procedures. Due to our intervention with ROM, patient care activities including elective surgeries, endoscopy procedures, dialysis, and routine patient care were not affected by interruptions or delays, which differed from other hospitals in our area. To return to routine care, clinical engineering flushed all main pipes for 5 minutes. Then healthcare personnel flushed each faucet for 30 seconds to ensure that fresh water from the repaired main was being supplied to the points of use. Clinical engineering performed internal water testing from the municipal water supply and water from the ROM for bacteria, endotoxins, and chemical particles during the boil water advisory. Test results are compared with AAMI guidelines, and all found to be within acceptable levels (see Table 1).

Table 1. Internal water testing from the municipal water supply and water from the reverse osmosis machines for bacteria, endotoxins, and chemical particles during the boil water notice

^a Reverse osmosis.

^b Colony-forming units.

^c Endotoxin units.

^d High.