By Karen Vian, RN, Communicable Disease and Immunization Program Manager, Douglas County Health and Social Services
Douglas County Public Health purchased lab-grade refrigerators and freezers in 2008. In addition, our main site and three satellite clinics are on a 24/7 NIST-certified temperature monitoring, which is broadcast to a secure website; alarms trigger both telephone and email notifications. We are very experienced with responding to false alarms that are triggered by frost/defrost cycling of units, vaccine doors left open too long during inventory and internet connectivity issues.
On the morning of Monday, January 30, 2012, multiple staff received telephone and email notifications that the temperature of one of our main refrigerator units was high and out of the 2-8 degree Celsius acceptable range. In responding to the alarm, we immediately noted that the temperature on the unit’s screen was high and out of range, a significant concern as the internet monitoring is measured by a separate monitoring system. An even bigger concern was that this refrigerator was stocked with 2170 doses of vaccine in readiness for the annual school law exclusion process and our annual Shots for Tots clinic.
Quick action on the part of clinic staff, management and IT employees helped to avert a costly loss of vaccine. Vaccine from the questionable unit was immediately moved into a different refrigerator unit, logged and counted, and designated ‘not to be used’ until the situation was fully understood. Because Douglas County Public Health administers approximately 9,000 doses of vaccine each year, our refrigeration and freezer units are physically separate units and we have more than one refrigeration unit in the clinic. This helps to spread the vaccine liability out as much as possible in the event of unit failure. Staff contacted the state immunization program immediately; they notified us that all vaccine remained viable. With internet monitoring, Douglas County was able to document the time at which the refrigeration unit failed and how long the temperature was out of range. We were also able to provide a graph of that day’s temperature to others to accurately describe and assess the situation. We called the refrigerator company’s tech support line and worked with public health staff to troubleshoot the problem. The tech support walked through the following questions:
- Is the probe bottle full of solution? If not, fill this up to the bottle shoulder.
- Is the evaporator fan inside the refrigerator spinning?
- Is the compressor fan on top of the refrigerator spinning? Is the compressor itself running?
- Is the condenser grill on the back of the refrigerator dusty?
- Is there any ice accumulation inside the refrigerator? If so, is it on the evaporator, the back wall, or both?
- Have the program parameters of the refrigerator been changed?
Because our refrigerator unit required troubleshooting past the above points, tech support recommended further troubleshooting be performed by a Bio Med or HVAC specialist. They informed us that a Bio Med or HVAC specialist will possess tools (e.g., volt-meters, pressure gauges) to further investigate the cause of the problem and to assess for other potential problems. We contacted an HVAC specialist, who arrived the following morning and worked by telephone with the unit’s tech support line to diagnosis the specific issue.
In summary, the refrigerator compressor motor failed. We learned that the motor was still under the 7 year warranty for parts (not labor). Prior false alarms were good training to avert what could have been a very real and very costly catastrophe and a very real recall for sub potent doses. The HVAC specialist returned 7 days later with a new compressor motor and fixed the refrigerator. The HVAC specialist also discovered that the air conditioning unit in the vaccine room was not working adequately. We monitor the room temperature in the vaccine room, and learned that it was 75 degrees at the time of the incident. Upon review of the online temperatures, it was noted that on or around January 19 the room temperature increased from baseline without explanation. A week later the refrigerator compressor failed. The HVAC specialists explained that if the room temperature gets too warm, the oil in the refrigerator’s compressor motor piping gets sludgy and can block the piping. They had recorded high pressure readings in the piping that verified this. In closer review of temperatures, the room temperature reached a maximum of 82 degrees during the time in question. Moving forward, we have installed a new air conditioner and have lowered parameters of the room temperature alarms. After monitoring the temperature in the repaired refrigerator unit for 7 days, the vaccine was placed back into the unit.
One additional lesson learned during our response to this issue is to develop and include a procedure to monitor the temperature probe solution regularly for possible evaporation and/or replacement. We found the temperature probe solution to be discolored and unsanitary in appearance in several of our refrigerator units.
So what is the cost of doing business in the vaccine management world?
Cost of Vaccines in the one Failed Unit: $62,288.97
Cost of Vaccine Management Equipment: $7,437.37
Lab-Grade Refrigerator with shipping: $4847.00
Glycerol for Probe Bottle Solution (32 ounce bottle): $25.00
TCP/IP Based Monitoring Device (up to 4 probes): ~$300/ea (one per room)
Heavy Duty sealed Probe: ~$40 to ~$75 (depends on length)
Monitoring Software: ~$500.00 + yearly support (to monitor all sites)
Voice Dialer: ~$250.00
Web Relay (allows the software to trigger the voice dialer): ~$130.00
HVAC Repair Services: $789.00
Replacement Air Conditioner: $517.02
Refrigerator Alarm Battery Replacement (6 size D): $4.35
Cost to Ensure Public Health: PRICELESS