Seattle Children’s Hospital: Preventable Disaster?

In May 2019, Seattle Children’s Hospital faced an emergency situation where 14 surgical rooms were forced to cease operations, with over 3,000 families potentially affected by deadly Aspergillus mold exposure. The Seattle Children’s hospital was forced to move or reschedule over 1,000 surgeries. Unfortunately, one patient recently died in 2018 after developing an infection as a result of exposure to this type of mold. Many more could face ongoing health complications.

How this could happen in this modern age of technology, to a hospital which, in 2019, U.S. News & World Report named one of the 10 best children’s hospitals in the country? In fact, U.S. News & World Report has recognized Seattle Children’s as a top children’s hospital every year since it began ranking medical facilities more than 25 years ago.

The looming question is “Was this tragedy preventable, and, if so, what should have been done?”

Who’s at fault?

According to the Centers for Disease Control and Prevention, Aspergillus is a common mold found both indoors and outdoors. Unless you live in a cleanroom or isolation room, you have most likely inhaled millions of it’s spores into your lungs every day since your birth.

While most people breathe in these spores every day without getting sick, the mold poses a real risk to those with compromised immune systems or lung disease. Mold growth can be accelerated and concentrated in man-made surroundings whereas in natural environments, the concentrations are diluted to just a few parts per million by global atmospheric conditions.  The way to prevent these spores inside closed spaces like operating rooms and patient rooms inside hospitals is to carefully monitor pressure, temperature and humidity.  As long as temperature and humidity are maintained a proper levels mold can not grow and if positive pressure is maintained the spores will, for the most part, be kept outside the area.

Aspergillus, and mold in general, can cause allergic reactions and infections in the lungs and other organs in the body. This is precisely why hospitals must monitor and manage mold growth of any type – patients in the hospital (children and elderly) are already at a greater risk for adverse effects of mold growth; even more so if they have existing health complications and compromised immune systems.

With that said, the Seattle Children’s Hospital had known deficiencies in room air purification systems. The patient who recently died (2019) contracted the Aspergillus mold infection a year ago.  That was known at the time and should have been a wake-up call to install equipment to monitor conditions to prevent a re-occurrence.  It is unclear which, if any, preventative or remediation processes were put in place after the first known incident. It is known, however, that they were largely ineffective in preventing further growth; the mold was still present a year later.

Ultimately, the Seattle Children’s Hospital is at fault – mold and other potentially harmful pollutants, of natural or synthetic origin, must be controlled no matter the cost.

What could have been done

There are dozens of monitoring systems available to hospitals, and some even provide advanced alerts when relative humidity and temperature levels become ideal for mold growth. These systems can allow for immediate correction of dangerous conditions.  An alert delivered in a timely manner can help maintenance personnel make adjustments to the HVAC systems and initiate clean-up measures to get rid of the mold.  Carefully monitoring potentially contaminated areas is a must for every health care provider.

Experts agree that having multiple environmental monitoring systems in place is a good idea; one tied in with a building management system, and another stand-alone as a fail safe. It is also important to note that any system which requires an employee to physically view a monitor or screen can only be as effective as the person viewing it. A better alternative is a system which includes a digital display of current values, offers a room or local alarm system when level are outside set ranges, and has the ability to notify key personnel via SMS, email and/or automated phone calls when issues of air quality occur. Many of these systems are specifically designed for hospitals, and include options to monitor both negative and positive pressure isolation rooms – helping to reduce exposure to mold and cross contamination.

Although there are only a handful of manufacturers that offer such comprehensive systems, they do exist, and are a fraction of the cost of having an incident like the one at Seattle Children’s Hospital. In fact, if you look at the math, a hospital could buy a comprehensive monitor for about the same cost it takes to operate a surgical room  – for 7 minutes.

Conclusion

Bottom line, there are no excuses. Hospitals operate on a tight budget, and have ongoing issues with accounts receivables from patients and insurance carriers. There are huge fees to surgeons, malpractice insurance, and other costs to operate a modern and efficient hospital.  However this is no excuse for overlooking something as basic as providing a mold free environment.  A piece of equipment as inexpensive as a modern advanced monitoring system to prevent mold growth and provide critical data on the health of the environment.  This solution does and will continue to have a huge impact of patient health and the ability to recover from surgery and the issues that brought the patient to the hospital in the first place.