April power outage accelerated two patients' deaths at Maastricht hospital

A power outage at Maastricht UMC at the end of April accelerated the deaths of two Covid-19 patients, was concluded in an independent investigation. The affected patients were already "extremely critically ill" with a "particularly poor prognosis" and very likely would have died without the power outage, but the outage was connected to their deaths, investigation leader Richard Dekhuizen said in a press conference on Friday, NU.nl reports.

The power outage occurred in one room of a nursing ward during the night of April 29 to 30. It was not immediately discovered. A 76-year-old man in that room died that same night, a 67-year-old man died two days later.

According to Dekhuijzen, the power went out in the nursing ward at around 11:00 p.m. on April 29. At 00:20 on April 30, a nurse saw on camera footage that a patient was moving restlessly. The nurse was in the room less than a minute later. They noticed that the Optiflow - the device that provided the patient with oxygen - was not working.

Because the room's door was closed due to the increased risk of infection, staff in other rooms did not hear the Optiflow's alarm go off when it lost power, the investigators concluded.

The nurse plugged the device into a different outlet and it turned back on. They then realized that a second patient's Optiflow also did not have power and switched it to a different outlet. In total, the two patients were without additional oxygen for around 75 minutes.

The Optiflow does not have its own emergency battery, which means personnel have to arrange alternative power supply in the event of an outage. The device has an alarm that sounds for two minutes if the power fails. "That is not a very penetrating sound Dekhuijzen said. 

The power outage originated in an earth leakage circuit breaker, which protects against short circuits, high leakage current, and overload. Exactly what went wrong with this circuit breaker, is not clear. 

Dekhuijzen added that the hospital should improve its communication with patients' family members. "At the time of the power failure, it was not entirely clear what exactly the purpose of the treatment with the Optiflow was," he said. Those involved were uncertain whether it was a treatment meant to improve the patients' condition, or just to make them more comfortable. "The doctors, nursing staff and family had different images of the usefulness of the Optiflow," Dekhuijzen said.

Karin Faber, director of patient care at Maastricht University Medical Center, acknowledged the investigators' findings and said that the hospital would adopt the recommendations in the report.