NJ Lawmakers to Delve Into Deadly Disease Outbreaks at Pediatric Facilities

Lilo H. Stainton | November 6, 2018 | Health Care
As new infections continue to be diagnosed at two long-term care facilities, legislators to investigate origin of the infections and what state can do to help in such crises

Credit: Office of Attorney General/Tim Larsen
State Sen. Joe Vitale
State lawmakers plan to hold a hearing early next month on the recent disease outbreaks at several New Jersey hospital operations dedicated to children’s care, including the Passaic County facility where a virus has killed ten youngsters with serious healthcare needs.

Senate health committee chairman Joseph Vitale said yesterday he wants to gather input from hospital leaders, infection experts and New Jersey Health Commissioner Dr. Shereef Elnahal about the origin of these infections and what state officials can do to reduce the impact of these crises.

In all, the outbreaks have sickened more than three dozen young, medically fragile patients — and one staff member — at three hospitals in recent months, but do not pose a threat to the public at large, officials have stressed.

As of Monday, 30 individuals have been infected by a serious strain of adenovirus at the Wanaque Center for Nursing and Rehabilitation in Passaic County, including ten patients who have died. A less serious strain of adenovirus sickened five patients with complex health needs at the Voorhees Pediatric Facility, in Camden County, but none have died.

In addition, bacteria discovered in the neonatal intensive care unit of Newark’s University Hospital have caused symptoms in three medically fragile infants there, and may be linked to the death of a fourth baby. These pathogens would likely cause mild cold-like symptoms in healthy individuals.

Emphasizing infection control

Hospital hygiene
As well as investigating these situations directly, the Department of Health launched a wider infection-control campaign last week to review operations at the state’s four pediatric hospitals, including Wanaque and Voorhees and two facilities operated by Children’s Specialized Hospital, in Mountainside and Toms River.

The DOH also plans to visit University Hospital, which was placed under a state monitor last summer when Gov. Phil Murphy raised concerns about the facility’s financial stability, quality of care, and its efforts to close certain pediatric units. Recent inspections by separate DOH teams uncovered no violations in Voorhees, minor problems at Wanaque and what they termed “major infection control deficiencies” at University.

Elnahal said last week that he is now talking to the federal Centers for Disease Control and Prevention about its new infection-control protocols, which are set to be phased in next year, and how the state can better protect these kinds of seriously ill patients, many of which depend on ventilators to breathe and feeding tubes for nutrition.

Credit: NJTV
New Jersey Health Commissioner Dr. Shereef Elnahal
The comissioner said the existing blanket regulatory standards for long-term care facilities “may be missing the unique needs and risks these patients face,” adding that the goal of his team is to “see if there is something we can learn from and move forward.”

While the state could advance stricter regulations on its own, Elnahal said that could result in confusion and inconsistent enforcement. “At this juncture, it is more prudent to explore possibilities with stakeholders at all regulatory levels,” he said.

But Vitale — who praised Elnahal’s effort to keep him informed on the outbreaks — said waiting on the federal government could take too long. “That’s like molasses,” the senator (D-Middlesex) said, adding, “I wonder if there are other responses or steps we can take” here in the Garden State. He hopes to hold a hearing on December 3, one of only a handful of days all legislators are scheduled to be in Trenton before the year’s end.

Need for careful surveillance

The New Jersey Hospital Association, which represents acute-care and long-term facilities like the pediatric hospitals, also has a role in addressing these outbreaks, explained vice-president of communications Kerry McKean Kelly.

The organization partners with the DOH to host a biannual conference on infection protocols, which play a big role in its ongoing quality-improvement efforts; it also stresses the importance of risk-assessment and careful surveillance of any infections that do occur. Similar efforts have helped facilities drive down the rates of sepsis, a blood infection that can attack patients in hospital settings.

“It’s very much a team-based approach, led by an infection prevention specialist but with buy-in from staff all across the facility — not just caregivers but housekeeping and other staff members,” McKean Kelly said. While this essential training is routine, the NJHA also holds specialized training when needed, she added, like the two-day session on personal protective equipment — gloves, gowns and masks — the organization hosted in October.

Although two of the outbreaks have the adenovirus in common, the DOH has stressed that Type 7 — which hit Wanaque — is far deadlier to medically complex children than Type 3, which was found in Voorhees. As a result, comparing the response of the two facilities is “in some sense comparing apples and oranges,” Elnahal said Thursday.

Wanaque unable to completely segregate patients

That said, there were differences in how the two facilities responded to the crisis. Elnahal said the Voorhees facility, with beds for just over 100 patients, had the space and ability to immediately separate patients who showed symptoms of the virus from those who did not. Voorhees officials first notified the DOH of the suspected outbreak on October 26, and have stopped accepting new patients, but are taking re-admissions.

But Wanaque, which cares for more than 90 pediatric patients, was unable to completely segregate patients with the adenovirus as a result of space constraints, Elnahal explained. That’s why administrators there agreed to stop all admissions following the outbreak, which was first confirmed and reported to DOH on October 9. Parents of patients there were informed of the outbreak ten days later; Wanaque officials have declined to respond to multiple requests for comment.

While the capacity to quarantine patients is not required for long-term care facilities like these, Elnahal said, “In the event of an outbreak, the ability to cohort patients helps significantly.”

In addition, when DOH teams visited Voorhees several days after the outbreak was first reported, they found no deficiencies. The October 21 inspection at Wanaque, however, identified a variety of infractions, albeit minor, related to infection protocols. For example, one nurse rinsed her hands for 13 seconds as opposed to the 20 seconds required, another touched a breathing tube after removing a soiled garment from a patient without changing gloves or washing hands, and a third caregiver touched her hair while attending a patient, without “performing hand hygiene” before returning to her duties.

Elnahal: ‘…we may never know the answer’

Elnahal said that while these infractions may seem minor, incrementally they could increase the risk for infection. “To the extent to which those citations can be attributed to the situation at Wanaque is an open question, and one we may never know the answer to,” he added.

Maintaining standards is a challenge, the commissioner added, and he said the violations identified at Wanaque do not necessarily reflect the ability of any one staff member. It takes extensive training, regular practice, and institutional support to ensure infection-control measures and other quality-care protocols are truly standard operations, he said.

“This is not easy to do,” Elnahal said. “And to do it 100 percent right, for every patient, is the challenge for quality improvement and patient safety programs.”