COLUMBIA, SC (WIS) - We now know it was multiple problems in the air filtration system at Dorn VA Medical Center that closed the hospital's operating rooms, causing the review of more than a thousand surgical cases.
On Monday, the VA invited us inside their surgical suite to show us it was the HEPA filters and a heat coil inside their air filtration system that caused the problems.
The operating rooms are cleaned after each surgery.
"We have dedicated housekeeping staff to the emergency room and they assist in turning those rooms over," said Ruth Mustard from Dorn's Patient Care Department. "We call it terminally cleaning, where they walk through and wipe everything down. It's very important to monitor that."
But it wasn't the cleaning staff who found the latest problem, closing all eight operating rooms Oct. 18.
"Supply technicians who were stocking the OR in the morning noticed some particles on supplies stored in the central core of the operating suite," said Mustard.
Three ongoing surgeries were completed, but the other 13 that day were canceled.
The VA didn't publicly announce the problem until we started asking questions. They showed us examples, claiming it was two disintegrating HEPA filters serving the operating room that caused the particulates.
"So this is the type of material -- you can see it falls apart -- this is the type of material that went into the system that we had to clean out," said Dorn VA engineer James Cook. "This is just paper, there's nothing toxic or of that nature."
What caused the problem with the HEPA filters?
"They're not sure exactly why," said Dorn VA associate director David Omura. "We've talked with the manufacturer, they said this is a complete anomaly; they've never seen this occur before."
They were about to reopen the OR's in November when more matter was found, this time from the heat coil. It was enough of an issue the hospital has gone back to review 1,076 surgical cases since June.
"Six cases were identified with surgical infections, but no correlation was found between the six cases and the presence of what was determined this particulate matter, this HEPA filter debris," said Mustard.
When we asked what type of health problems are associated with this issue, we didn't get a direct answer other than an infection. Engineers have increased the access points to the air filtration system so further inspections can be done.
"We've replaced the HEPA filters and we re-looked at the entire system to include the air handler and the air flows to make sure everything is within parameters, and they are right now," said Cook.
The hospital says the surgical suites are sterile again and ready for surgery.
The hospital is taking the rest of the week to review the system and get all of the equipment cleaned and returned to the operating rooms. They expect surgeries to resume on Monday.