Jamaica Observer / The indoor air quality issues plaguing Cornwall Regional Hospital (CRH) in St Jams reportedly emerged about a decade ago. Since the problem resurfaced in recent months, the Ministry of Health put together a chronology of the issues. The report, which basically tells the story of an extremel sick building, was prepared in January this year, and revised and updated in March.
Cornwall Regional Hospital (CRH) was built in the 1970s and the first to fifth floors were ventilated with central air conditioning. Approximately 25 years ago, these systems were removed and adjustments made to ensure adequate cooling of the air using split air conditioning units. The original ducting system was never removed or rehabilitated completely.
A review of available documents indicates that there had been reports of indoor air quality (IAQ) concerns from the first to fourth floor since 2009 affecting the first floor — radiotherapy; second floor — Western Regional Health Authority (WRHA), laboratory and Accounting Department; third floor — radiology; and the fourth floor — offices of the senior medical officer.
Investigations were carried out by the occupational health and safety officers with assistance from the National Public Health Laboratory Environmental Engineer and the general findings included among others:
1. Poor ventilation.
2. Improper ventilation systems.
3. The presence of pathogenic organism.
4. Odour nuisances.
5. The presence of volatile organic compounds.
6. Faulty sewage/plumbing.
7. Improper chemical storage and handling.
8. Untrained staff/poor worker hygiene.
9. Inconsistent servicing and maintenance of equipment.
HISTORICAL AIR QUALITY REPORTS AT CRH 2009—2015
The following are some of the episodes that have been investigated and recorded since 2009 to present:
• November 20, 2009 — Cytology and Histology Labs (Pathology Department); workers complained of respiratory illness attributed to poor ventilation and fume hood use.
• August 13, 2010 — Western Regional Health Authority Offices; workers complained of flu-like illnesses. CO2 levels for the offices were 1800 ppm and the recommended CO2 level for indoor air is 800 ppm.
• April 31, 2011 — Report on complaint investigation for A E Department; workers complained of flu-like illnesses.
• January 11, 2013 — Indoor Air Quality investigation for WRHA and A&E Department resulting from extensive mould growth on ceiling tiles.
• May 22, 2013 — Indoor air quality volatile organic compound (VOC) test conducted due to poor air quality affecting regional director, audit room, Histology and Microbiology Department.
• May 7-8, 2014 — Indoor air quality event in the Pharmacy Chemotherapy Mixing room and Radiotherapy Oncology Department; workers complained of severe skin irritation resulting from poor ventilation of these departments.
• August 22, 2014 — Cornwall Regional Hospital Chemotherapy Suite complaint — investigation indicated that the main issues were improper ventilation and operation procedure of chemotherapy drug.
• September 12, 2014 — Report on investigation done at the Radiology Oncology Department, Cornwall Regional Hospital — skin itching and offensive odour experienced while working in the Chemotherapy Suite.
• February 10, 2015 — Air quality event in Oncology Department; workers complained of rotten egg smell in the department in the mornings.
• February 5, 2015 — Poor air quality affecting ENT Department resulting from mould on the ceiling tiles.
• February 26, 2015 — Air quality event in Blood Bank, Cornwall Regional Hospital, resulting from poor air quality.
• March 13, 2015 — Air quality event, episode 2, Blood Bank; workers complained of feeling tired, exhausted, tightening of the chest and skin irritation, with some smelling a burning rubber scent.
• March 31, 2015 — Air zone sample analysis report for Blood Bank; air test due to poor ventilation in the department.
• April 20, 2015 — Indoor air quality volatile organic compound test conducted for Blood Bank and Radiology resulting from improper ventilation.
• April 30, 2015 — Indoor air quality volatile organic Compound test conducted for reception and X-ray Dark Room resulting from improper ventilation.
• March 25, 2016 — Air quality event, episode 3 at Blood Bank; workers complained of smelling chemical coming from in the vents; burning of skin, eye and nose; tightening of the chest. Some workers were seen in A&E and given sick leave.
CURRENT INCIDENT 2016— PRESENT
Earlier in 2016, (April/May 2016) the laboratory and Accounts Ddepartment were closed due to an event that resulted in staff complaining of skin irritation symptoms — burning, itching and rashes; respiratory symptoms — coughing, shortness of breath, chest tightness, loss of voice and sore throat; and neurological symptoms — weakness, dizziness, skin tingling and numbness.
The incident was thought to be as a result of the use of chemicals in the dark room in radiology that is on the third floor above laboratory. The chemicals were being discarded using the plumbing system that ran in spaces where fumes could get into the ventilation system. The ducting systems are all interconnected and diffusion of gases can occur across departments on the same floor and above or below the floors. The piping system was found to have leaks and defects.
Early September 2016, after rehabilitative works were completed, the Accounts Department staff became symptomatic as before. Investigations revealed that the rehabilitative work was incomplete — areas were not completely sealed, extraction of air was inadequate to allow proper ventilation, and old batteries for the server room were to be removed. The radiology team also complained of similar symptoms and evacuation occurred of that department. Investigation revealed that there was a chemical spill in the dark room and improper chemical storage (formaldehyde in the CT room). Corrective actions were taken.
In October 2016, staff members continued to experience symptoms on the second and third floors with the Medical Records Department being severely affected. Services at the hospital were scaled down to emergencies only and clinics, and elective surgeries were suspended and some urgent services referred to primary care.
Environmental Solutions Limited
Environmental Solutions Ltd was contacted to investigate. The company deployed its heating ventilation and air conditioning (HVAC) consulting engineer to the hospital to conduct the investigation. The findings were as follows:
1. Stored chemicals used to develop X-ray films and possibly other chemicals leaked into spaces on the floors below.
2. The spilled chemicals found their way into duct work. This may have carried the chemicals and other odours to other areas on the hospital.
3. Vibration of the concrete slab due to “chopping” the floors in the affected dark room and other areas may have caused the release of trapped gases on to the floors.
4. There was no emergency ventilation system in the dark room to exhaust the odour to the atmosphere.
5. It was observed that no fresh air was being pumped into the affected areas.
6. No fume hood or direct exhaust ventilation system was on the chemical storage closet.
7. Return/extraction ductwork was being used to remove odours. However, an air supply duct was found connected to the system. This would have been sending odours back on to the floors.
The presumptive source of the odours and leaks has been considered the X-ray dark room on the third floor where stored and disposed chemicals used in the development of radiographs had been leaking for a considerable but undetermined time and had soaked into a section of the concrete floor. Chemical wastes from the radiograph process have historically been disposed of down the drain.
Symptoms of discomfort experienced by staff were similar to what was stated in the Materials Safety Data Sheets (MSDS) for chemicals used the in dark room. Physical evidence suggested that the dark room was the source of the chemical leaks and the metallic taste being experienced may have been due to a “bio reaction”.
Testing was subsequently undertaken to determine the type of gases/substances that may have been released. A certified laboratory in New Jersey, with which the ESL internationally accredited laboratory works, was contacted and the circumstances and proposed approach explained. The international lab agreed with ESL’s recommended approach. They confirmed the methodology for assessment and recommended monitors to be used. Once monitors were received and calibrated, they were set up to take measurements in spaces where the effects were being felt — dark room, radiology, etc. The gases tested for were acetic acid, sulphur dioxide, and hydroquinone.
The results of the tests indicated an absence of all the parameters tested for. The consultants therefore suggested that, going forward, all remediation works should be conducted under well-ventilated conditions wherever possible. In addition, appropriate personal protective equipment such as gloves, chemical suits, respirators, etc, should be used.
While the results of the tests were being awaited, the team of HVAC and civil engineers, and environmental health professionals (including the EHU) began working on solutions to decontaminate the space. The engineers also traced and assessed the drains to ensure that there were no trapped gasses. Drain pipes were cleaned, and it was recommended that the floor be sealed with epoxy to prevent any possible escape should gases be entrapped.
During the ongoing assessments, three incidents of high concentrations of gases were released onto the floors after ceiling panels were removed in the respective areas. This indicated that there were pockets of the gases in the ceiling plenum and in the spaces between the webs of the roof. Some of the spaces between the webs are sealed and, therefore, any gas possibly in that area cannot escape, except by moving laterally until it finds an opening. While there are other considerations for the continued production of the gases, no definitive sources could be identified.
Assessment indicated that not all areas had access to outdoor sources of air, so it was recommended that the existing system be used to extract any trapped gas.
A contractor was hired by the Western Regional Health Authority and the Facilities Management Unit for cleaning and decontamination of the affected spaces and partial rehabilitation of the HVAC system. The partial rehabilitation of the system was to allow for extraction of contaminated air and replacement with fresh air.
In January, the system was brought back up and complaints about skin irritation, respiratory difficulties, eye irritation, etc, re-emerged.
ESL’s investigation revealed debris being discharged from the “rehabilitated” system. This debris, when tested, indicated the presence of fibreglass. It was then noted that some of the ducts in the HVAC system were insulated internally with fibreglass and cleaning had stripped the deteriorating insulation. ESL advised immediate cessation of cleaning and that those ducts should be removed and replaced on a phased basis.
The CRH plan was to get the central system up and running. However, a few design changes MUST be implemented to properly isolate the individual areas as needed from possible outbreak or ventilation issues. Spaces within the HVAC system and ceiling are currently interconnected, and therefore the spread of air is facilitated. It was also determined that one air handling system from the west plant room covered the areas affected on the second and third floors — Medical Records Physiotherapy and Surgical Clinic.
Based on the situation and reference to ASHRAE, NFPA 45 & SMACNA, several recommendations were made.
• Many of the issues identified relate to an obsolete HVAC system which needs to be upgraded to meet the changes made in the operations of the hospital. Poor ventilation and inadequate air circulation are causes for concern.
• When the partially rehabilitated system was restored, existing debris within the ducts, inclusive of fibreglass residue, was dispersed on the floors.
• Most of the symptoms currently being experienced by hospital personnel seem to be related to the dispersion of fibreglass residue. (Can be transported from one floor/area to another by clothes, shoes, etc.)
• The current practice of chemical management and handling in the hospital is a major issue that requires sensitisation and training. Going forward, the following programme has been laid out:
• Evacuation of affected areas to facilitate isolation and decontamination.
• Isolation of existing areas that cannot be relocated from the hospital.
• Erection of temporary housing for those facilities that can be relocated.
• Procurement of an HVAC engineer to design a new system for the hospital.
• The current HVAC has been shut down and will remain out of commission.
• Based on the design, procure and install a new HVAC system.
• Other parallel activities that need to take place include sensitisation and training for management of chemicals and upgrading of the maintenance system for the hospital.
During the period February 15 — 21, 2017, health care workers presented with mucosal and airway symptoms reportedly experienced while at the Cornwall Regional Hospital. The most common presentation was upper airway irritation and eye irritation. Skin rashes and burning were noted on the exposed areas, primarily forearms, neck and face. People with chest discomfort described a heavy retrosternal sensation, but no shortness of breath or cough. Dizziness resulted in syncopal attacks in two individuals.
The UDC was engaged to oversee the designing and implementation of a HVAC system to replace the existing system that appeared to be the main issue behind several manifestations of the problem.
The environment health team continued to do weekly assessments at the hospital, and environment sampling for qualitative and quantitative analysis of fibreglass, particulate matter, heavy metals, volatile organic compounds, and inorganic compounds were done. Based on these results, extensive cleaning and decontamination was done in several areas of the hospital. Test results showed asbestos in some unused areas of the hospital and asbestos abatement exercises were done.
Despite these measures, there continued to be complaints. The Pan American Health Organization (PAHO) sponsored a team consisting of an industrial hygienist and a laboratory technician to undertake in-depth sampling and testing for chemical, biological and physical agents.
MOULD GROWTH – PAHO Assessment March 2017
The PAHO report revealed that the main problem seemed to be of biological origin, specifically related to fungal growth in the building envelope. Most of the symptoms reported by the staff members and the mould growth in the building indicated damp building-related illnesses (DBRI). Surface and mould sampling indicated medium to high levels of fungi growth and spores.
There was a significant problem with water intrusion in the building envelope. There are leaks from different origins and condensation in many parts. This was identified as a problem that needed to be addressed and might be the main cause of the mould growth. After the moisture issue is resolved, mould removal was recommended according to standard procedures.
The results of the monitoring of other contaminants were not significant. Measurements show very low levels of volatile organic vapours, indicative that there is no vapour generation (organic nor acidic) in the problem areas. The results indicated that there were no chemical sources that could cause indoor air problems. The temperature and relative humidity is close to the recommended levels in some areas and high in other areas. The ultra-fine particle (UFP) counts are very high in some areas. This is a problem in all the clean rooms (surgery, ICU, nursery, dialysis, etc), indicating that the HEPA filtration system is not working properly.
The main problem to be resolved is the refurbishing of the HVAC and the filtration system. The HEPA filtration system should be corrected to comply with the applicable particle count standard. All the AC split units in the hospital areas should be replaced for other systems that allow outside air supply and air filtering. All the AC units supplying air to clean areas (operating rooms, ICU, dialysis rooms, nursery, etc) should have a proper filtration system.
The glass fibre air ducts should be replaced with metal ducts and alternate linings that do not contain fibreglass. The fibreglass ducts should not be cleaned, but replaced to prevent the intrusion of dust, fibres and spores into the hospital. The ventilation set-up in the operating rooms should be redesigned to provide laminar flow and positive pressure.
UNOPS TECHNICAL ASSESSMENT – February 2018
The United Nations Office for Project Services (UNOPS) carried out a technical assessment of the hospital in January 2018 and the following were the main findings:
1. Structural – Civil
• Basement column need urgent repair and immediate shoring to avoid further deterioration and potential collapse.
• Water held in ceiling membrane of basement is to be evacuated.
• Roof drains and waterproofing need to be totally replaced and newly installed asphalt membrane to be protected.
• Water supply pipes to be replaced due to their age and numerous leakages.
• Seismic resistance improvement required.
• In general terms, the electrical installation in its current state can be classified as high risk of fire and also with a high rate of exposure to electric shocks through direct and indirect contacts. As such, it requires urgent action to avoid imminent emergency situation
• About 90 per cent of the inspected panels are not properly sealed or enclosed. There are signs of oxidation, dust accumulation, the circuit breakers and cables are loose, the busbars are rusty, and there are problems with electrical grounding, inadequate IP protection rating, and obstruction to access. It is recommended that all panels be replaced.
• The wires, conductors, cables and their connections are in unsafe conditions with expired insulation lifetime (according to manufacturers, lifetime is about 20 to 30 years). It is suggested to replace them.
• The general distribution panel is obsolete, the protection system and the load transfer require repair and maintenance, and its service life must be evaluated.
• The transformers room is in direct contact with water, does not have adequate insulation and contains objects and other prohibited equipment which create a high-hazard environment.
3. Medical Gases
• Fifth floor OTs network needs to be replaced as it presents high risk due to quality of repairs and connections.
• The boiler needs to be urgently relocated. It is oversized and it operates in a high temperature environment that presents a high risk of fire.
JAMAICA: An extremely sick building Ministry of Health chronology shows problems affecting Cornwall Regional Hospital from 2009
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