Date: Wed, 29 Mar 2000 17:18:32 -0700

Lax controls at Scripps cited after infections

Inspectors say La Jolla hospital failed to stop exposure to fungus

By Cheryl Clark

STAFF WRITER

March 29, 2000

Seriously ill patients at Scripps Memorial Hospital were exposed to a potentially lethal fungus because of lax infection controls at the La Jolla facility, according to state health investigators.

In a 19-page report, the investigators declared the hospital "failed to prevent and control aspergillus cases during construction" and "failed to maintain a sanitary environment" to prevent and control sources of contamination "that may have contributed to the increased incidence of aspergillosis cases."

During extensive remodeling at the hospital over a recent three-month period, inspectors said, 16 patients were found to have the fungus. Six of the patients died at the hospital. An autopsy, performed on only one, discovered "severe aspergillus bronchopneumonia of both lungs."

"Without an in-depth medical record review, it could not be determined if aspergillosis was the primary or contributing cause of death for the five other deaths," the state investigators reported.

Aspergillus is an airborne mold or fungus that is common in the environment. It is found in decaying vegetation, insulating material and walls or ceilings, and can be released in dusty environments, especially during construction.

It is harmless to healthy humans, but when inhaled by people with weakened immune systems or who are severely ill, it can cause lethal disease in the lung or other organs.

The Division of Licensing and Certification, a branch of the state Department of Health Services, compiled its statement of deficiencies after Scripps officials on Jan. 28 reported a cluster of aspergillosis cases at the 450-bed acute care hospital.

A team of state inspectors, on behalf of the federal government, spent a week inside the hospital and detailed numerous infection-control regulations the hospital failed to meet.

Such inspections are required by state and federal law, and if corrections are not swiftly made, the hospital's ability to receive reimbursement for Medicare and Medi-Cal patients could be at risk. The state's findings were released along with the hospital's plan of correction.

Scripps' chief medical officer, Dr. Brent Eastman, yesterday disputed many of the conclusions in the state report, saying most of the cases were patients who brought the fungus with them when they were admitted rather than acquiring the mold inside the hospital. He said that was the case with the one patient who died. The patient's name has not been released.

Eastman said that all cases mentioned in the state's report involved extremely elderly and sick patients, and those who died did so because of underlying illness.

Added Chris Van Gorder, Scripps' chief of health care operations, "The hospital has been clean and is always clean, and, frankly, now it's cleaner than it's ever been before." The hospital notified the state "the minute we found we had an increase" in aspergillosis cases, he said.

State officials said they reviewed numerous patient records and hospital reports and discovered 20 patients with sputum cultures positive for aspergillus exposure between Oct. 28 and Jan. 28. Of those, the state says only four were determined to have been acquired before the patient was admitted to the hospital.

For the remaining 16, the first positive sputum culture occurred three or more days following admission, according to state investigators. Of the 16, 12 were in the intensive care unit before the first positive culture and 10 were in the surgical intensive care unit, the state maintains.

Six of those 16 patients died at the hospital, many perhaps from their underlying illness.

One common denominator among those who died was that they had been in Rooms 701 to 723 before the first positive sputum culture, according to the report.

Chris Cahill, a state infection-control inspector who routinely investigates hospital outbreaks, said such incidents occur only about three or four times a year in California. Often, as mysteriously as they arise, they disappear.

State officials said they discovered many of the problems while the Scripps La Jolla hospital was engaged in construction and remodeling projects, and which may have led to the aspergillosis cluster.

Investigators surveying the intensive care unit in early February found surfaces, including windows, bed frames, emergency resuscitation equipment and shelves that "were heavily coated with a layer of white dust."

"The intensive care unit had white powdery and dusty surfaces throughout on medical equipment, equipment holders, curtains/drapes, beds, counters and windowsills. Patient rooms that were 'ready' to receive a patient were noted to be dusty," the report said. "The dusty surfaces were in patients' rooms, hallways, nurses station and medication/treatment rooms.

"On Feb. 1, it was determined that construction was in progress on the first floor without the use of airtight barriers or HEPA filter vacuuming to prevent dust and debris contamination."

State officials also detailed a problem area between a fire door leading to the windy helicopter pad and the surgical intensive care unit.

"This pad was used two to three times a day to deliver trauma patients to the emergency room and generated large amounts of dust and debris that could blow into the ICU area through the fire door and open windows," said the report.

And, the report continued, about 500 yards away, "heavy excavation and construction was in progress."

"These factors were not investigated by the infection control practitioner or the hospital epidemiologist to determine what relationship, if any, these environmental factors influenced the increased incidence of nosocomial (hospital-acquired) aspergillus cases," the report said.

The state report also concluded that Scripps infection-control officials neglected to discuss the outbreak officially among themselves until Jan. 20, several weeks after the cluster had become apparent, and neglected to report the cases to the state until Jan. 28. State regulations require that such incidents be reported.

The report faulted the hospital for not having an infection-control official on the construction crew, which would have enabled officials to monitor areas for construction-related debris that could contain infectious quantities of mold.

That, said state inspector Cahill, may be the most serious of Scripps' deficiencies.

"They failed to follow their own policies and procedures," she said. If the infection-control official had been present, "she could have instructed workers about proper barriers that should have been made when they have to get into the ceiling or do construction."

Scripps officials said they have taken steps to correct every deficiency mentioned in the state report. And, they emphasized, for whatever reason, no cases of aspergillosis have been noticed since the end of January.

Unfortunately, Cahill said, much about the aspergillosis cases may never be understood.

"Obviously they had some problem someplace, but what the problem was we will never, ever know. All we can do is take the appropriate precautions to make sure people doing construction are doing their job to make sure infection-control procedures are followed."

Copyright 2000 Union-Tribune Publishing Co.