The rehab floors at UVM Medical Center’s Fanny Allen campus in Colchester will reopen this fall after investigators were unable to pinpoint a specific reason why 21 nurses fell ill in April and May.
Nurses repeatedly reported dizziness, confusion, and nausea over a four-week period. It was at least partly caused by nurses using too much disinfectant to slow the spread of Covid-19, according to Vermont Department of Health radiological science program chief Bill Irwin, who conducted the investigation.
However, the nurses displayed such a diverse array of symptoms that it was impossible to find an obvious smoking gun, Irwin said.
“It’s always nice if you got some sort of problem, you go right in and there it is,” Irwin said. It’s solved, and “it won’t happen again.”
More often than not, he added, “it’s a complicated process.”
Even without a clear answer, nurses and patients will move back to the facility this fall. This week, UVM Medical Center announced upgrades that will allow them to reopen the closed floors of the Colchester campus in October.
Dawn Lebaron, vice president of hospital services for the hospital, said she was “100% confident that we’d be OK.”
“I would put my mother in there as a patient,” she said. Lebaron noted that a staff advisory group had opted to return to the facility rather than remaining in their temporary space on the main campus.
The Department of Health report marks the second time in 12 months that investigators haven’t been able to find a specific cause for a strange illness affecting nurses at Fanny Allen.
Last October, 17 staff members reported feeling nauseated after smelling exhaust-like fumes in an operating room. On Nov. 27, seven staff members reported a similar smell and symptoms.
After each incident, two staff members were found to have low levels of carbon monoxide in their blood. UVM Medical Center closed the operating rooms at Fanny Allen for two months last winter to investigate.
The medical center ultimately installed carbon monoxide detectors, added air filters, upgraded the kitchen exhaust symptoms, and asked employees to wear carbon monoxide monitors.
Investigators never conclusively determined the cause of that incident, but surmised that it may have been caused by higher-than-normal carbon monoxide levels, such as truck idling close to an air intake or an issue with the natural gas boilers.
That issue was unrelated to the most recent event, Irwin determined. The nurses affected last year worked in the outpatient operating rooms — a separate part of the building from inpatient rehab units — and consistently reported a smell that seemed to be associated with their symptoms.
Carbon monoxide poisoning was among the hypotheses that Irwin and other agencies debunked in their investigation. Among their findings: there were no pesticides or hazardous chemicals on the site; no one maliciously added chemicals to the hand sanitizer dispensers; nurses’ personal protective equipment was not faulty or contaminated; there was no mold in the ceiling tiles or electromagnetic fields; state police determined that no one had tried to poison the nurses.
Irwin finished his report on the most recent spate of incidents on July 16. It was not released publicly, though VTDigger requested it this week.
At least part of the problem, he found, is that nurses used too much disinfectant, likely as they tried to minimize the spread of Covid-19. They may have inadvertently combined chemicals, he said. That may explain why different people were affected at different times, and why no patients or doctors were impacted.
Falling sick due to cleaning chemicals “is not uncommon,“ Irwin said. Such incidents “are reaffirmations of all of our efforts in public health to try to make sure that people follow the directions when they work with chemical products.”
In his report, Irwin chastised Fanny Allen administrators for providing staff an “unauthorized” cleaning chemical, called Oxivir Five 16 concentrate. After the medical center ran out of wipes typically used to clean their keyboards and workstations, they replaced it with a concentrated hydrogen peroxide disinfectant, which is not meant for frequent use. Even so, the misstep likely wasn’t the culprit. The cleaning product can be mildly irritating to the skin, but “is unlikely to be responsible for the symptoms reported,” Irwin wrote.
According to Lebaron, UVM Medical Center presented the findings to staff and jointly came up with a plan to prevent similar issues in the future. The hospital will review cleaning products and processes and train staff on “chemical hygiene.” They’ll install carbon monoxide monitors and set up a response plan if nurses do get sick in the future.
The staff illnesses are “like a black cloud for us,” Lebaron said. “It’s extremely distressing.” But, she said, when it comes to investigating and addressing the underlying issues, “everything that’s been done has been done.”
“There’s no way we’d send them back if we didn’t feel confident,” she said.
Correction: An earlier version of this story incorrectly stated DOH’s Bill Irwin was critical of staff for overuse of disinfectants. He was critical of hospital administrators.
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