Administrators and senior staff of the Karl Heusner Memorial Hospital (KHMH) are meeting around the clock in an effort to rectify an apparent oversight in the Neonatal Intensive Care Unit (NICU) that has resulted in the deaths of twelve babies born prematurely in just 20 days. As we reported yesterday, authorities say that five of those babies died from complications of prematurity, but the remaining seven are confirmed to have died from contracting a bacterium known as Enterobacter cloacae, belonging to the same scientific family as such disease-causing bugs as salmonella and E. coli. Medical Chief of Staff Dr. Adrian Coye emphasized that the bacteria could have come from anywhere.
Dr. Adrian Coye – Medical Chief Of Staff, KHMH:
Whether is was brought from other parts of the hospital, I cannot say. But I know from an epidemiological point of view, when you look for an outbreak you try to identify an index case. An index case was identified in February, the first infection of that nature. However that baby was treated and went home. It could be then that from that original infection, colonization had happened and that’s how you talk about how things are spread, and so that may be one source.
The point is there are many people who end up having to go through the Special Care Nursery.
The unit has been shut down for two weeks to a month for renovations, despite having been cleaned as recently as three weeks ago and its air conditioning changed in December. Reports say there have been deaths as far back as December that parents believe may have been linked to this bacteria but Dr. Coye dismissed the charges as being “unlikely” given the patterns found in the preliminary report. But how did the hospital not react faster when it began to see multiple deaths in the ward? On average per month there are five to six neonatal deaths for various reasons, but CEO Dr. Gary longsworth admitted that this spike was first brought to their attention after a parent spoke to the press.
Dr. F. Gary Longsworth – CEO, KHMH:
Over a very short period of time beginning last week we had a cluster of deaths in our Neonatal Intensive Care Unit and it went out to the media. One of the parents went to the media, I believe, that actually prompted the investigation because up to that point we were not aware that the situation was developing. It really became apparent when the babies died in significant numbers in a short period of time.
Later Dr. Coye noted that unnamed staff members in the ward reacted to the rising number of deaths by changing certain procedures. But the fact remains that someone slipped up somewhere and the hospital aims to find out. Chandra Nisbet Cansino, chair of the Hospital Authority Board of Governors, reiterated the determination of the hospital to rectify the error, including meeting with grieving families.
Chandra Nisbet Cansino – Chairman, KHMH Board Of Governors:
Because my first instinct was to come here and to find the person that was to blame and deal with that person. There are so many more technical issues to that. We got an explanation to the system of the blood culture. That takes a week. That is not something that is a deficiency of the lab, a blood culture takes five days to grow, and there’s no way around that. There was no other way of determining the sensitivity of an organism, except by doing a blood culture. While you’re waiting five days for a blood culture, babies were passing away. That little cluster of time was where we lost some of the babies without knowing it was because of this particular bacteria. The second purpose of our meetings is still to have a discussion with staff. We still have not gotten a lot of reports to determine if anybody is culpable. We have not established that at this time, and that is a process that is still under investigation. The most important purpose for us being here today was for us to sit-down and have a discussion with some of the parents of the deceased children. Unfortunately they went to the media before coming to us. That is totally understandable. We have no problem with that, but we needed to hear from them about their experiences. They shared a lot of information with us. They had suggestions and recommendations for us. We haven’t met all of them, and we’re hoping to meet with all of them, but that was basically the most important part of the day for me, because we really needed to hear from them.
Investigations into the matter continue.