Jun 10, 2009 6:47 pm US/Eastern
I-Team: Report On MCH Baby Deaths
MIAMI (CBS4) ―
An investigation by health department officials found that shortly after two infants died at Miami Children's Hospital in March, half the sinks in the Neonatal Intensive Care Unit and 75 percent of the faucets in the unit showed signs of the same type of bacteria suspected in the deaths of the babies.
Seven-day-old Anthony Malinconico and 21-day-old La'ziea Skinner died within 24 hours of each other. Both babies were born premature and were particularly susceptible to infection.
Although no definitive source of the bacteria was found, the Miami Dade County Health Department's report focuses on potential problems with the plumbing system at Miami Children's Hospital, noting that the "root cause" of the deadly infections "appears most likely to be related to environmental factors."
And health department investigators noted "that corrective measures needed to be taken to address the compromised water quality on the NICU floor."
According to the health department, the hospital's "engineering staff indicated that there are currently no policies or procedures in place for routine inspection and testing of the hospital plumbing system."
The report, written by the health department's principal investigator, Dr. Vincent Conte, revealed "the facility also does not systematically flush their system and the hospital does not utilize Miami-Dade County's chlorine purge program" which is intended to cut down on the amount of bacteria in a hospital's plumbing system.
But in a press conference held late Wednesday, Conte refused to say that he was certain the two babies that died contracted the Pseudomonas infections at Miami Children's Hospital, saying since they couldn't match the exact strain of the bacteria to the 23 different strains of Pseudomonas they subsequently found in the NICU, he couldn't be certain where the bacteria came from.
The presence of Pseudomonas bacteria is not unusual, officials stress, but hospitals are urged to do everything in their power to limit a patient's exposure to the bacteria – especially premature infants whose immune systems are weak and vulnerable.
The report also revealed for the first time that the number of cases involving Pseudomonas was much higher than previously revealed. In addition to the two babies that died, and a third baby that was seriously ill from a bacterial infection, eleven other infants also showed signs of Pseudomonas "colonization."
The health department said colonization – a term describing the presence of the bacteria in the babies – did not result in a serious threat to the children.
Investigators also paid special attention on Room 2 of the Neonatal Intensive Care Unit (NICU). The two babies who died, and the third that was seriously ill, all spent time in that room.
"A walk through of the NICU by County and State Health Department officials demonstrated a sink in Room 2 that, when used, generated an excess amount of `splash' that landed on environmental surfaces adjacent to patient care areas," Conte wrote. "That raises the possibility of contamination from a sink to patient care areas or equipment that could be used for patient care. Past studies of Pseudomonas outbreaks in NICUs have suggested that the combination of biofilm buildup in plumbing systems, combined with splash from sinks in improperly designed rooms can result in contamination of patient care areas."
Following meetings with the health department, Miami Children's Hospital closed off that room in May and stripped out all of the sinks, fixtures and plumbing.
Attorneys for the families of Anthony Malinconico and La'ziea Skinner said they had not yet seen the health department's report. Both declined to comment until they had a chance to review it.
The health department outlined a series of steps the hospital should take, including regularly flushing the system to prevent bacterial buildup, installing splash guards at the sinks in the NICU, create buffer zones of at least three feet surrounding the sinks, and possibly even moving the sinks away from where the babies are housed.
In response to the report, Miami Children's Hospital released the following statement:
"The hospital has worked extensively and cooperatively with the Miami-Dade County Health Department. The department conclusively determined that there was no causal connection between the deaths of the two infants and patient care practices. The report also confirms that the hospital's infection control practices are consistent with established standards.
"We're pleased to report that many of the recommendations made by the Miami-Dade County Health Department were already routine practices," the hospital statement continued. "The remaining recommendations are being reviewed and will be acted upon as appropriate."
The hospital did not reveal which of the recommendations they were following and which they were not. They also did not address the central issues surrounding the plumbing system and "compromised" water supply.
(© MMIX, CBS Broadcasting Inc. All Rights Reserved.)
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