By Daniel Gilbert and David Gutman / The Seattle Times
SEATTLE — When the third child in three months developed a mold infection after heart surgery, Seattle Children’s Hospital executives launched an investigation they hoped would be a model for others to follow.
In the spring of 2005, they formed an outbreak response team to pinpoint the source of the infections, reviewed medical charts, swabbed equipment for contaminants and took air samples in operating rooms. They found small amounts of the Aspergillus fungus in and near an operating room but concluded they were “unlikely to have caused infection.” The main suspect: a dirty nitrogen tank, near an operating room, contaminated with mold.
Children’s was so confident that it published the investigation in a journal in 2007 and presented it at a hospital conference. Separately, the hospital fought a nearly three-year court battle opposing claims that its air-handling system caused a 12-year-old girl’s Aspergillus infection.
Last week, in the wake of a recent spate of Aspergillus infections, Children’s Chief Executive Jeff Sperring announced a stunning reversal: Hospital staff now believe the system that circulates air through operating rooms caused mold infections going back to 2001.
That wasn’t the hospital’s only abrupt shift. Shaken by the revelation that at least 14 patients have been sickened and six have died of Aspergillosis, Children’s announced it would install air filters long known to be effective in blocking tiny particles. Sperring said the hospital was moving to “the highest level of filtration found in operating rooms today.” Children’s has closed 10 of its 14 operating rooms until the custom-built filtration systems can be installed.
Children’s repeated struggles to eradicate mold from its operating rooms have forced it to reschedule or delay surgeries, opened it to new litigation and put a cloud over the reputation of the esteemed pediatric hospital.
But the hospital’s disclosures raise questions that executives so far have declined to answer in detail. After infections spanning 18 years and allegations implicating its air-handling system, why has the hospital only now reached this conclusion? Why didn’t the hospital install the superior quality air filters — currently used for three of its operating rooms — for all of them before now?
Lindsay Kurs, a spokeswoman for Children’s, said the hospital had carefully investigated each case in which a patient contracted Aspergillosis after undergoing surgery, but until this year the results were largely inconclusive.
After identifying problems in its air-filtration system in May, Children’s reviewed “historical data” and determined “that these past infections were likely caused by deficiencies in the air-handling systems that serve our operating rooms,” she said.
Based on inspections the hospital conducted in May and November, it believes “gaps between the air filters allowed air to bypass the filters,” Kurs said. Children’s decided in May to install new high-efficiency particulate air — or HEPA — filters in each operating room, and accelerated those plans this month after detecting Aspergillus again.
“We will conduct a rigorous, thorough review of the factors that led to this situation,” she said, adding that Children’s “will examine our culture, our leadership, and how our teams communicate problems and escalate concerns.”
Susan Mask, chair of Children’s board of trustees, said in a statement that Sperring has the board’s “full support — and the authority — to do what is necessary to make this right.” She declined to comment on whether the board planned to take disciplinary action against any hospital staff.
The retooling of filtration systems comes as Children’s again confronts allegations in court that it has caused Aspergillus infections.
In late October, the parents of a teenager sued Children’s, alleging the hospital “failed to take reasonably prudent measures to prevent Aspergillus from infecting” their son, leaving him disabled. The infection occurred during brain surgery for a tumor that turned out to be benign, according to Tyler Goldberg-Hoss, a lawyer representing the family.
The risk of Aspergillus infections to hospital patients broadly has been well documented for years.
Most people breathe in the mold daily without getting sick, but patients with lung disease or weakened immune systems — especially organ- or stem-cell-transplant patients — are at higher risk of developing Aspergillosis. In the most serious cases, symptoms range from a fever to coughing up blood, according to the Centers for Disease Control and Prevention..
Around the same time that Children’s investigated the Aspergillus outbreak in 2005, Eugene and Clarissa Patnode filed a lawsuit alleging that the hospital’s air-filtration system was deficient and had led to an infection that permanently disabled their daughter, then 12 years old. Lawyers for the Patnodes specifically pointed to Children’s lack of HEPA filters as a cause for their daughter’s infection, claiming the hospital’s “filtration system does not filter Aspergillus spores.”
In opposing the claims, Children’s argued in a 2008 court filing that experts hired by the Patnodes couldn’t determine “the number of spores that even allegedly reached the air intakes, much less entered the operating room.” The case was settled a few months later. In response to questions from The Seattle Times, Children’s apologized to the Patnode family.
Allegations of Children’s failures to maintain its HVAC system stretch back more than a dozen years, when former staffers said they found mold in the fan coils and drain pans, and dead birds and droppings plugging the air-intake system, according to court documents in the Patnode lawsuit.
In May, after the hospital notified the state Department of Health that it had detected Aspergillus spores in operating rooms, inspectors cited the hospital for maintenance failures. By then, Children’s had identified six Aspergillus infections in surgical patients in the past two years.
As Children’s faces mounting scrutiny over its response to the Aspergillus infections, it has provided a script to employees with talking points ranging from how to respond to parents anxious about a child’s surgery to statements it has made to media organizations.
Among the questions in a document marked “staff use only”: “Is Seattle Children’s hiding information or lying to the press?” It didn’t definitively answer.
“We took appropriate legal steps to protect the identity of our patients and the confidentiality of our quality improvement information,” the document says. “We continually strive to be transparent and accountable while also honoring the privacy of our patients and families.”
Seattle Times staff reporter Ryan Blethen contributed to this story.