Critical Care Plus: Unsanitary Conditions Lead to Shakeup in Kansas City

A hospital in kansas city, mo, is undergoing an inquiry after a report that maggots were found in the noses of ICU patients.

The incident happened 4 years ago but only came to light recently in research published by Richard Beckendorf, MD, a physician at the Kansas City Veterans Affairs Medical Center where it happened, and Stephen Klotz, MD, who was the hospital’s chief of infectious disease at the time and now is an infectious disease specialist at the University of Arizona Health Sciences Center.

Beckendorf, Klotz, and colleagues reported on the incident in a recent journal article that drew significant attention because the effect on patients was so disturbing.1 They report that the Kansas City Veterans Affairs Medical Center "experienced an infestation of mice combated in part by broadcasting poisoned baits. Months later, there was an invasion of flies into the hospital, and two comatose patients in an intensive care unit contracted nasal maggots."

The incident did happen, but some facts are in dispute, according to Glenna Greer, a spokeswoman for the hospital. Beckendorf and Klotz report that adult flies were trapped and maggots were removed from the nose of the second patient. Subsequent examination determined that they were green blowflies (Phaenicia sericata). The journal report blames the incident on poor housekeeping practices—the result of staff cuts that made it impossible for workers to adequately clean some parts of the facility.

A Mouse Infestation

"Recent downsizing of hospital personnel had led to the unintended and unrecognized loss of housekeeping services in the canteen food storage areas," they wrote. "A mouse infestation of the hospital occurred, with the epicenter in the canteen area. This was initially addressed by scattering poisoned bait and using rodent glue boards. The result of such treatment was the presence of numerous mouse carcasses scattered throughout the building, attracting the green blowfly. Adult gravid female flies trapped in the new intensive care unit (where mice were not present) laid eggs in the fetid nasal discharge of 2 comatose patients."

To make matters worse, the problem went on for 2 months after the first discovery. The first patient was found with maggots on July 22, 1998, and died 2 days later of unrelated causes. Maggots were found on the second patient on Sept. 30, 1998.

Greer confirms that there was a mouse infestation, which in turn led to the fly problem. But she disputes some allegations in the journal study, including anecdotes about mice being so pervasive that they ran over the feet of executives during a boardroom meeting. And she says rumors that nurses kept some mice as pets are false. Greer says the mice initially took up residence in a food storage area serving the employee canteen, but she denies charges that the infestation was made possible by staff cuts that diminished housekeeping. She also suggests that many of the mice were displaced from a construction site next door to the hospital and just fled to the nearest building.

Beckendorf says the ICU problem was solved with live trapping of mice and removal of carcasses, which eliminated the fly infestation. But that wasn’t the end of the nightmare.

"The cause-and-effect nature of the mouse carcasses and flies was underscored a year later when an outbreak of P sericata occurred in the operating department and was linked to the presence of mouse carcasses on glue boards not removed the previous fall," he says. "Hence, the disruption or loss of one vital link in hospital organization [in this case, housekeeping support] may lead to an unintended and bizarre outcome."

One question was asked by many observers after the Kansas City problem came to light: How could the clinicians not know that flies were laying eggs in their patients? One clue is the short time between when eggs are laid and when maggots emerge. For the green blowfly, this period is short, between 24 and 48 hours. Greer says the ICU nurses discovered the maggots during routine care and were removed before causing any tissue damage.

The situation remained under the radar until the journal article focused publicity on the hospital. Then Secretary of Veterans Affairs Anthony J. Principi reassigned two senior administrators at the hospital and ordered independent reviews of the facility and launched two investigations.

Reference

1. Beckendorf R, et al. Nasal myiasis in an intensive care unit linked to hospitalwide mouse infestation. Arch Intern Med. 2002;162:638-640.