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Human toll: Families didn’t know about germs

Nancy Blume died after contracting CRE in one of Florida’s largest outbreaks. Blume’s family and many health professionals weren’t told about the supergerm.


The CDC came a year too late for Nancy Blume.

Silver-haired, petite, and weak from colon cancer surgery, the 65-year-old grandmother entered the extended-stay hospital in poor health, with an abdominal incision nearly a foot long.

Kindred Hospital Bay Area-St. Petersburg was supposed to be a place where she could rest and recover enough to begin chemotherapy. But she didn’t live long enough to start.

Blume died at Kindred exactly three weeks after her arrival, infected with a deadly dangerous gut supergerm known as CRE.

Such germs are easily spread by health care workers who move from patient to patient, if they fail to wash hands and change gloves, or incompletely sanitize hospital equipment.

That’s exactly what investigators from the CDC found in a report on the CRE outbreak where Blume died on Jan. 26, 2010.

“X-ray and ultrasound machines, scissors, and glucose meters were not cleaned and disinfected after each patient use,” they wrote.

They spent 40 hours watching staff there on the job, and concluded that hand washing happened less than one-third of the time it should have. Between March 1, 2009 and Feb. 28, 2011, they counted 99 people who acquired CRE while at Kindred St. Petersburg, some merely colonized, others infected. A case study of 34 “probable CRE transmission” cases found nearly half had died by the study’s end.

Few health professionals in Florida are aware of the outbreak, due in part to a health system focused on preserving the confidentiality of not just the patients, but of the hospitals themselves. And family of the people who died? None contacted by The Palm Beach Post knew their relative had been infected with hospital-acquired CRE. But once they looked in the medical records, they found the proof. The Post found families through newspaper obituaries.

The CDC’s report did not specifically name Kindred St. Petersburg but Kindred executives acknowledged that it was at the center of the outbreak.

The CDC investigators focused on the likely cause of the germ’s spread: People.

“Lapses in hand hygiene were noted among HCP (health care personnel) before performing procedures, after exposure to bodily fluids, and before and after contact with the patient and the patient’s environment,” the investigators wrote. “Nonadherence to glove use was noted during preparation and administration of medications, and gloves were cut open to palpate veins during routine diagnostic venipuncture.”

Nurses felt their duties were overwhelming, leading to high staff turnover.

The report’s top recommendation:

“Decrease the patient-to-nurse ratio on the medical/surgical units to facilitate adherence to infection prevention measures and reduce staff turnover.”

Kindred helping CDC

Asked about the CDC’s findings, Kindred corporate executives in Louisville, Ky. said the publicly traded company is playing a leadership role in combatting CRE by working with the CDC. But they also minimized the size of the outbreak and disputed suggestions that their hospitals are understaffed for the complexity of the patients they treat.

“We have long recognized that we run the risk of becoming a haven for people with infections. We have been cooperating with the CDC for years,” specifically in tracking how infections spread, said Dr. Sean Muldoon, senior vice president and chief medical officer of Kindred’s hospital division. “We helped them design their data systems.”

He pointed to a scholarly paper written jointly by CDC and Kindred officials. It noted that 99 patients had tested positive for CRE during their stay, and 21 developed a CRE blood infection. But because most were categorized as “possible” transmission cases, not “probable” transmission cases, meaning they might have brought the germ from outside, Muldoon disputed the significance of the outbreak. He couldn’t comment about individual cases because of medical privacy laws.

“We are down to four cases that actually got sick by it,” because of their stay at Kindred, he said. “This is the sophistication of the counting. There does not appear to be a strong relationship between the presence of CRE and death.”

However, a year after the CDC inquiry ended, it noted in a report that no criteria exist for concluding whether a patient’s death is from his underlying illness, or his antibiotic-resistant infection.

Multiple studies have found that CRE increases the likelihood of death. The CDC has warned repeatedly that as many as half of all people with a serious CRE infection typically die and notes that people infected with CRE have a higher death rate for all causes.

Muldoon said Kindred, one of the largest long-term acute care hospital chains in the nation, has a strong record of helping severely ill people go home sooner.

“We’ve got 5,600 patients in our hospitals on any one day. There are many people who are unhappy. There are tons of people who are happy,” he said.

60 percent of patients tested

As Blume arrived at Kindred on Jan. 7, 2010, the St. Petersburg hospital was in the 10th month of the CRE outbreak.

The hospital had 82 beds. At the time Blume was there, 10 patients a month were developing sepsis, blood infections, with multi-drug resistant germs. Tests showed Blume had CRE in her urinary tract and in her respiratory secretions. She also had sepsis showing E. coli.

At its peak, prevalence of the “nightmare” germs reached 60 percent of patients tested, the CDC found.

Muldoon noted that prevalence refers to everyone who tested positive for the germ at any time during their stay, and doesn’t indicate new cases. By the end of the study period in February 2011, the percent of screened patients with newly detected CRE went from 44 percent to zero.

The CDC now points to the outbreak as a success story, one that proves that CRE can be stopped.

In Blume’s medical record, a doctor described her as an “unfortunate woman,” which she certainly was, for a multitude of reasons.

Her entire adult life, Blume had battled bipolar disorder. The lithium she had taken over decades had damaged her kidneys, and increasingly, it wasn’t working. As she grew sicker, she told the Kindred doctors that she didn’t want dialysis.

Blume’s daughter, Pearl James, was in Kentucky, struggling to manage her mother’s health care needs from afar. Leading up to the cancer diagnosis, her mother’s bipolar disorder had been growing worse.

“She was belligerent. She would get hysterically religious. She’d sing at the top of her lungs, she’d go on huge shopping sprees at the dollar store,” recalled James, an English professor. James looked for a hospital or nursing home that would take her mother, finally settling on one in the Tampa Bay area, where her mother had lived for years and still had friends and family.

Two weeks after Blume’s arrival at the nursing home, things seemed to be going well. But not for long.

“She calmed down and made friends. She had her cellphone, we talked every day,” James said. But then a call came that her mother had been sent by ambulance to the hospital, and they had to do emergency surgery for a cancerous colon tumor.

“It was impossible for me to be in two places at the same time. I had just buried my grandfather, cleaned out his house and put it on the market,” James said.

After the surgery, her mother went to Kindred St. Petersburg to recover. James prepared to visit, but never got the chance. She remembered the final phone call.

“It was Florida. The hospital. I was expecting them to ask for permission for a new medicine or an update. They weren’t. They were calling to say she was gone,” she said. “I was completely, completely shocked.”

Long-term acute care hospital patients rotate in and out of other hospitals as they need surgery or more intense care. As a result, drug-resistant outbreaks at one facility are a problem for all in a region. By the end of the CDC’s inquiry, five of six hospitals in the Tampa Bay area had patients with CRE.

Array of bad germs

One was a half-hour’s drive from Kindred St. Petersburg, at Kindred Hospital Central Tampa. That’s where, six months after Blume’s death, Leonard Zalac encountered a constellation of multi-drug-resistant germs.

The retired 73-year-old police officer’s decline began with a fall at home that dislocated his shoulder. He had Parkinson’s disease, and it made him unsteady.

He spent the next month in Spring Hill Regional Hospital in Hernando County, where he developed aspiration pneumonia, a lung infection caused by inhaling food or mouth secretions. Once he was doing better, his doctors felt he needed to recover for a few more weeks at a rehabilitation hospital, where he’d receive physical therapy.

But three weeks after he was admitted to Kindred Hospital Central Tampa, Zalac was dead from sepsis.

His widow, Ruth Zalac, said the doctors didn’t really explain what had happened. But she saw this in medical records: A naso-gastric tube insertion scratched him up so badly he bled from his mouth and into his lungs; an inexplicable middle-of-the-night code call forced him onto a ventilator; the oxygen from the wall broke, no one knew how long it was out. He developed a sudden fever that climbed past 104 degrees. A cooling blanket meant to keep the fever down malfunctioned, and water poured all over the floor.

Four years later, time has stopped for Ruth Zalac. She confines most of her life to the Spring Hill bedroom where her husband slept. She wakes up looking at his picture, at the medals and badge he wore, at the Father’s Day balloon that was in his hospital room those final days, and at the flag that draped his casket.

All this time, she has kept his medical records in her garage, certain that they held the answers to what went wrong. In fact, they did.

They show that on his arrival at Kindred Central Tampa, his digestive tract was colonized with one type of antibiotic resistant germ that didn’t respond to Vancomycin. But after nine days at Kindred, his throat, lungs and bladder became infected with two types of carbapenem-resistant germs. One had spread to his blood. He went into heart failure on July 9, 2010. The next day, his fever spiked to 104.7.

“I would just sit there and rub his arm. I didn’t know what to do,” said Ruth, 75.

By July 17 Leonard Zalac was dead. The Air Force veteran was buried at the Veterans Cemetery in Bushnell, honored with the Fraternal Order of Police’s standing guard.

Long-term acute care hospitals like Kindred are gathering points for patients who have been on a wide array of antibiotics for a long, long time, people with wounds that won’t heal and lungs that struggle to breathe. As a result, the extended-stay hospitals are among the riskiest places on Earth to catch CRE and other multi-drug resistant germs, studies show.

The CDC has concluded that across the nation, about 18 percent of long-term acute-care hospitals, like Kindred, have treated CRE infections, compared with less than 4 percent of short-term acute-care hospitals.

Infectious disease doctors are well aware that such hospitals are hot spots for drug-resistant germs. But they say information sharing beyond individual patient records must improve.

Less than an hour’s drive from Kindred St. Petersburg is Florida’s only National Cancer Institute designated hospital, H. Lee Moffitt Cancer Center. Many of its patients are undergoing chemotherapy, making them immune compromised and especially vulnerable to such infections.

Dr. John Greene, the infectious disease director at Moffitt, said he first heard of the CRE outbreak in April, when The Post sent him a copy of the CDC’s outbreak report.

In response to a records request from The Post, the Florida Department of Health in Pinellas County said it had discussed the CRE cases during regional group meetings of infection control specialists and produced a “to whom it may concern” letter that it says was issued to health providers throughout the area.

The letter was dated Dec. 6, 2010, four months after Leonard Zalac died. It didn’t name any affected hospitals.

Greene said Moffitt has been taking precautions with patients transferred from long-term acute care hospitals, as well as nursing homes, for years.

“Those are breeding grounds for drug-resistant organisms and CRE, and we know it,” he said. “We do much more vigorous cleaning of the rooms, we have ultra-violet machines that zap the rooms between patients, we are ultra-tough on use of gowns and gloves.”

In Spring Hill, Ruth Zalac said she wanted everyone to know what had happened to her husband, so that something positive might come from her tragedy.

“He was not an old man, we had a life ahead of us, and they just took him,” she said, still bewildered. “We were laughing before the transport to Kindred. We were laughing. I never expected him not to come home.”



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