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Add another chapter to the book of Things That Can Keep a Risk Manager Awake at Night. A hospital in Kansas City, MO, is undergoing an inquiry after a report that maggots were found in the noses of intensive care unit (ICU) patients.
The scenario also raises questions — again — about how a hospital can have such a problem and then breeze through its Joint Commission survey a month later. And it highlights how staff cuts, even in nonclinical areas, can be detrimental to patient care.
The incident happened four 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 the incident 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 their 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.
"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 dis- charge of two comatose patients."
To make matters worse, the problem went on for two months after the first discovery. The first patient was found with maggots on July 22, 1998, and died two 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."
The Cornell Lab of Ornithology in Ithaca, NY, reports that blowflies are commonly used by forensic investigators studying time and cause of death because they are immediately drawn to dead bodies, and the life cycle of flies yield clues to the time of death. According to Novartis Animal Health at Novartis.com, the adult blowfly lays its eggs in moist areas, especially those soiled with feces, urine, or mucous. After hatching, the larvae feed on the epidermal tissues and skin secretions of the host animal, causing extensive tissue damage. Once the larvae have completed feeding, they drop to the ground where they disperse and burrow into the soil to pupate. Once they become adults, the emerging flies mate and seek a warm, humid place to begin the cycle once again.
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. The targeted managers were the regional network director and the deputy director.
"VA has an obligation to provide quality health care to America’s veterans," Principi said in announcing the dismissals. "Failure to maintain sanitary standards is unacceptable, both with employees and with managers charged with maintaining standards."
Principi directed the Inspector General of the Department of Veterans Affairs to immediately undertake two investigations. One will deal with the current condition of the Kansas City Veterans Affairs Medical Center, and the effect of any deficiencies on the quality of care and patient outcomes. The second investigation will deal with the adequacy of supervision by both the VA’s central office the regional leadership, specifically regarding their ability to monitor health care operations.
The two administrators are temporarily reassigned pending the outcome of the investigations. Even with the investigations, the negative publicity from the incident may be the worst outcome for the hospital. The hospital’s risk manager was not available for comment, but Greer says the hospital apparently has escaped any legal liability, possibly because there were no actual injuries tied to the infestation, leaving only the disgusting nature of the problem.
"The physicians called the patients’ families at the time and explained the situation," Greer says. "There have been no negative repercussions, no indications of any lawsuits of investigations."
In fact, the incident seems to have slipped right by the Joint Commission investigators. The hospital was scheduled for its triennial survey in August 1998, only one month after the maggot incident and the surveyors made no mention of the problem, Greer says. She says she does not know if hospital staff or leaders volunteered a report on the incident.
"We scored 96 out of 100," Greer says. "We got a Type I recommendation for a pharmacy cart left unattended and for the way we evaluated agency nurses. There were no references to the fly problem and our corrections were in place by then."
A spokesman for the Joint Commission confirms that there was no investigation of the incident in 1998, but he says there might be one now. Mark Forsteneger tells Healthcare Risk Management that "the Joint Commission will evaluate it" now that the situation has been brought to their attention, and there is no statute of limitations on actions previously unknown to them. The fly problem does not constitute a sentinel event because there was no death or serious physical or psychological injury, he says.
"The report will go into the organization’s complaint history, and that is available to anyone," he says. "There is no time limit on how old a complaint can be, so an incident from 1998 still can be entered."
1. Beckendorf R, Klotz SA, Hinkle N, et al. Nasal myiasis in an intensive care unit linked to hospitalwide mouse infestation. Arch Intern Med 2002; 162:638-640.