Seattle Children’s hospital has upgraded its air-filtration system and is no longer in danger of being removed from a federal program for patients using Medicare and Medicaid.
The medical center ran afoul of the program’s requirements earlier this year after Aspergillus mold sickened three surgical patients on the hospital’s Seattle campus. Children’s attributed the mold to problems with its air-filtration system. Three other patients were infected by the same mold in operating rooms last year, and one of them died several months later.
The Centers for Medicare and Medicaid Services (CMS) was set to terminate Children’s Medicare provider agreement on Sept. 19 but notified the hospital Monday that its pending removal from the program had been dropped.
The state Department of Health (DOH) performed a surprise inspection at the hospital Aug. 7 and found it to be in compliance with state requirements, according to state records.
Four operating rooms were closed May 18. Children’s reported the mold problem to DOH on May 20. The remaining 10 operating rooms subsequently tested positive for Aspergillus and were closed May 24. About 1,000 surgeries were postponed; others were moved to other facilities. Children’s reopened the operating rooms on July 4.
Inspections by CMS and DOH in May found the hospital deficient of effective oversight for “quality improvement, infection control” that “put patients at risk of harm from pathogenic organisms.” That inspection determined, partly through a review of 2018 and 2019 maintenance records, that the hospital was failing to ensure staff had “completed preventive maintenance of the hospital’s air handling system according to industry standards and manufacturer’s recommendations.”
The 2019 inspection turned up various instances between July 2018 and April 2019 of technicians failing to complete routine maintenance on exhaust fans or replace pre-filters on air-handling systems on a regular basis.
While the air-handling systems have been identified as the likely cause of Aspergillus mold getting into the operating rooms this year, the mold didn’t appear because of the pre-filters not being changed according to protocol, Children’s CEO Dr. Jeff Sperring said.
The state and federal agencies have both signed off on the hospital’s plan to address its deficiencies.
“I’m really pleased and proud after all the work, we got validation from the Department of Health and CMS that they did get a chance to verify our work and do feel like we are where we need to be,” Sperring said.
The three infections in 2018, including in the patient who died, were likely because of small gaps in the walls of two operating rooms, said Dr. Mark Del Beccaro, the hospital’s chief medical officer. The rooms were temporarily shut down in June last year for remediation work.
The 2019 infections were likely caused by a gap in the array of small air filters used to catch smaller particles like mold. That air-handling unit has been shut down and a new unit is being installed, Del Beccaro said.
Sperring said Wednesday that he takes responsibility for the hospital’s failures.
“We clearly let our patients and families down,” he said.