Our community has trusted White Memorial Medical Center (WMMC) to provide quality and compassionate care for nearly a century. We take this trust and our mission to serve very seriously. It’s why the staff at WMMC has notified families of infants being cared for in our Neonatal Intensive Care Unit (NICU) that a common bacterium, called pseudomonas, has been found in an unusual number of infants.
The presence of the bacterium was discovered on November 30 and has been aggressively addressed. Since November 30 we have treated 33 infants in the NICU. There has been one infant death that we believe could be related to the presence of this bacterium. There have been four other infant deaths since November 30. Medical records show it is unlikely that the bacterium played a role in two of these cases. Infants in the NICU typically face critical health circumstances. Many are born prematurely or critically ill. They often have immune systems that are already compromised, and their health conditions may vary due to a number of serious health factors. We don’t know at this time if the bacteria played a role in the other two infants who died. The charts of these five infants have been sent out for external, independent review to definitively determine the cause of death, and we will know the results of that review within several weeks.
The hospital has communicated with the families of these infants. We are working closely to keep all these families updated. We sympathize with any concerns they may have regarding this situation. We have and continue to provide our NICU infants with all appropriate care and concern.
The hospital immediately notified local health agencies about the situation, including Acute Communicable Disease Control at the L.A. Department of Public Health, and consultants with the Centers for Disease Control and the California Department of Health Services. The hospital has been working closely with these agencies in investigating the situation and is currently implementing all their recommendations.
At this point we believe the bacterium was spread through the use of a specific instrument called a laryngoscope blade that may not have been properly cleaned and disinfected, but we will not know until we have completed the full and complete investigation that is now underway in collaboration with the public health agencies.
The laryngoscope is a lighted tube used to look at the inside of an infant’s larynx (voice box) through the mouth. The laryngoscope is used with a small attachment, called a “blade†because of its shape (it is not a cutting instrument). The laryngoscope is used to insert a tube into the infant’s windpipe when medication needs to be introduced into an infant’s lungs, or when an infant needs to be placed on a ventilator to help him or her breathe, in a process called intubation. The laryngoscopes involved in this situation were of a smaller size that could only be used on infants.
The hospital has implemented all precautions for care of these infants:
> Antibiotics have been given to all infants in the NICU since November 30.
> As of December 4, the NICU remains closed to new admissions until a full and complete review is conducted. Four critically ill infants born at the hospital since Nov. 30 were placed in special isolation rooms next to the NICU to receive care.
> All infants who have tested negative for the bacteria are held in separate areas.
> Nurses have utilized full protective coverings when caring for infants and the same nurses attend to the same infants to reduce the risk of cross contamination.
> Procedures have been reviewed and changed to ensure laryngoscope blades are properly cleaned and disinfected and labeled each and every time before use.
> An internal investigation of all department policies and procedures related to infection control has been initiated.
> All infection control policies and procedures are being re-emphasized and strengthened hospitalwide.
In addition, two pseudomonas infections have been identified in our Pediatrics Intensive Care Unit (PICU). As a precaution, we immediately and voluntarily closed the PICU to new admissions, and nurses on this unit began utilizing full protective coverings to reduce the risk of cross contamination. We have a total of three patients in the unit. Because of the presence of pseudomonas in one infant and one toddler in the PICU, we are working diligently with the public health agencies to investigate, and we will implement any recommendations they have for the PICU.
Our first priority is to continue to work with the families affected by this situation. WMMC is totally committed to providing our patients with quality medical care in a safe and comforting environment. If the public has any questions regarding this situation, please call 1-888-771-1883.