Official: Mistakes made handling fungal outbreak

A top safety official at Children’s Hospital on Thursday acknowledged a “weakness of surveillance” in failing to identify an outbreak of fungus until five infected patients were dead and the hospital called in state and federal agencies to investigate nearly five years ago.

Dr. John Heaton, the hospital’s associate medical director for patient quality and safety, also said officials “dropped the ball” by failing to tell family members of children who died with the rare fungal infection that their kids were victims of an outbreak in which the culprit dwelt in hospital linens.

“We failed to do what we should have done, pure and simple. We dropped the ball,” Heaton said at a news conference. Five years later, Heaton, an anesthesiologist, said he made the calls Thursday to three families of children who contracted mucormycosis, then died at Children’s, in some cases shortly after they were diagnosed.

Heaton called it “clearly an error” to ignore those families. While he apologized profusely for how the hospital handled the family notifications, he still emphasized that the hospital doesn’t believe the fungal infections were the primary cause of death for the young patients.

The hospital’s mea culpas came amid mounting questions over its initial response to the spate of rare infections from a ubiquitous fungus that Heaton equated to bread mold.

Among the toughest questions were those from Cassandra Gee, who connected the dots between her infant son’s death at the hospital in 2008 and a news account this week that detailed the outbreak. The rash of deaths in infected children only came to public light through a medical journal article written by investigators with the U.S. Centers for Disease Control and Prevention.

On Thursday, Gee visited attorney Carey Wicker, who said he plans to file a negligence lawsuit early next week against the hospital.

Hospital officials refused to discuss individual cases, citing federal privacy laws.

Gee’s son, Tyrel, was a premature baby who died in August 2008, just days after a lesion appeared on his groin. Gee recognized her infant son as matching the description of the first patient to develop the fungus in a story by The Times-Picayune.

“She’s shell-shocked, because she never got a satisfactory explanation. They told her her child died of sepsis,” Wicker said. Hospital officials still had not reached Gee by late Thursday, he said.

Heaton touted “extraordinary measures” the hospital took once similar lesions were found on two patients in 2009. Those steps included steam-pressurization of hospital linens and arriving at the linen theory in the first place, which CDC later validated.

“However, there are portions of what we did that, with the clarity of hindsight, were not perhaps adequate,” said Heaton, flanked by the hospital’s newly appointed CEO, Mary Perrin. “It’s personally appalling to me that we find some of the families are finding out their child was involved in this outbreak by reading the newspaper.”

Heaton went on, saying the lapse “was not done to conceal anything, nor was it malice aforethought. I think in our zeal to comply or go above the standards of compliance with a focus on stopping the infection, we forgot those who came before.”

At least one family of a child who died after contracting mucormycosis in the outbreak blames the hospital, the state, doctors and a linen company for the ravages their son endured before dying.

In a lawsuit filed in 2010, Stephen Tyler and Dorothy Malik allege that doctors failed to promptly order a biopsy of a black spot first noticed on their 13-year-old son Zachary’s armpit in March 2009. Zachary was the fourth of the five children who were infected in the hospital’s fungal outbreak. The attorney for his parents, Harry Widmann, has declined to comment on the case.

State and federal health officials, meanwhile, have praised the hospital for jumping into action in 2009 once an outbreak was suspected.

But an earlier report by CDC doctors, in January 2011, shows that by then, four children had died, all between August 2008 and March 2009, after being infected with the fungal disease. One of them later was determined to have been infected outside the hospital.

Hospital officials pieced together those cases only later, despite regular death reviews at the hospital and a detailed protocol for infection surveillance.

Heaton said the fungal infection, which occurs only in people with extremely weak immune systems, was deemed to be a “contributory” cause of all five deaths, but not the primary cause.

That meant that a requirement under hospital policy to conduct a “root-cause analysis” of all infections that originate in the hospital and “result in death or major permanent loss” didn’t apply, Heaton said.

Still, he acknowledged that the hospital could have connected the dots between the four earlier deaths if it had taken a broader view. He said the hospital has started looking at a wider set of cases to avoid what he called “tunnel vision.”

“Why we didn’t notice the spike in incidents, I don’t know,” Heaton said. “Most of the time (in death reviews), you’re looking to make sure the care rendered was appropriate to the patient. When the primary cause is judged to be something else, a premorbid oddball fungus doesn’t always fit into a larger picture.”

At this point, Gee doesn’t buy the idea that her infant boy died from something other than the fungus infection, her attorney said.

“He was in the ICU for being premature and he had this fungus and it was catastrophic and killed him within a couple of days,” Wicker said. “He appeared to be thriving. He developed this sore and rapidly degenerated and then he died.”

Dr. Raoult Ratard, the state epidemiologist, praised the hospital for ferreting out the rash of fungal infections and acting quickly once it did.

“I think the hospital should be credited for really understanding infections and putting things together,” he said.

He said such infections are extremely unusual, striking only patients with extremely fragile immune systems.

“It’s rare, but it does (appear). So when you have one here and there, you try to find where that comes from, and you don’t know,” Ratard said. “It’s not really obvious.”

Still, Ratard described a difficult process in determining a primary cause of death in cases with multiple afflictions, saying, “Deciding which one is the main cause is arbitrary.”

Tom Chiller, a medical epidemiologist for CDC who was part of the investigation team, said it was difficult to blame the hospital for failing to identify the rash of infections early on.

“In an ideal world, we would connect all these dots, but we’re dealing with hundreds of different infections at a hospital. Even when we know there’s an outbreak, it’s exceedingly difficult to identify some common cause,” Chiller said. “Sometimes it takes that next case to actually put it all together because there’s some kind of smoking gun.”

Heaton acknowledged that some of the infections might have been prevented had the hospital caught it sooner.

But Heaton also defended the hospital’s decision not to spread word of the outbreak to the public. At the time, he said, “Nobody was out there in the community at potential risk from this. All of the patients who had been affected had passed away. Patients in the ICU didn’t seem to have similar lesions.”

The hospital scrapped its linen provider and took other measures that rid it of the fungus, according to the CDC report.

Heaton said medical professionals who needed to know about the outbreak were informed of it. But Dr. Brobson Lutz, a former city health director who specializes in infectious diseases, said he only learned of it over the weekend. Lutz has been critical of the hospital for not broadcasting the discovery to alert hospitals around the world.

Although Heaton noted that mucormycosis is not on a list of diseases that hospitals in Louisiana are required to report, Lutz said the deaths should have been deemed “sentinel events” that require deep scrutiny. “A bar cannot be low enough that a hospital administrator can’t get under it,” he said.

Lutz also worried that the outbreak may never have been caught had a watchful hospital staffer not recalled a similar lesion on another recent patient and alerted the hospital’s infection control department.

“I’m glad they had two together,” he said. “If they hadn’t had those, they might still be having them.”