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. 2004 Apr 26;24(2):95–108. doi: 10.1016/0195-6701(93)90071-7

A multidisciplinary investigation of a cluster of deaths on a paediatric intensive care unit

H Maguire ∗, J Watson ∗,∗, R George †, L Taylor †, V Murray ‡, D Penny ∥, M Rigby ∥, P Taylor ∥, H Gaya ∥, L Durman §
PMCID: PMC7134500  PMID: 8104983

Abstract

During late December 1989 and early January 1990, a cluster of six unexplained deaths occurred on a paediatric intensive care unit (PICU) among children with congenital heart disease who had undergone cardiac surgical procedures. The children were all aged three years or less. In each case death was preceded by an unexpected increase in ventilatory pressure requirement followed by the development of a similar pulmonary shadowing on chest radiography. The radiological abnormality was felt to be consistent with a pneumonitis associated with some small airway disease. The clustering of these deaths, occurring in a similar unusual manner, was felt to constitute an outbreak warranting investigation. An Incident Committee was established to plan and manage a large multidisciplinary investigation during which the unit was temporarily closed. Following extensive investigation no bacterium, virus, fungus or other pathogen, toxic agent, or any other explanation for the cluster of deaths could be found. The possibility that the cluster occurred by chance remains although this was felt to be unlikely.

Keywords: Outbreak, investigation, nosocomial, multidisciplinary, paediatric intensive care, congenital heart disease

References

  • 1.Hospital Infection Control . June 1988. Guidance on the Control of infection in hospitals prepared by the joint DHSS/PHLS Hospital Infection Working Group. [Google Scholar]
  • 2.Illness on a paediatric intensive care unit. 5th ed. Internal publication of the Public Health Laboratory Service; London: 1990. p. 1. (Communicable Disease Report). (01) [Google Scholar]
  • 3.Lyrene RK, Truog WE. Adult respiratory distress syndrome in a pediatric intensive care unit: predisposing conditions, clinical course, and outcome. Pediatr. 1981;67:790–795. [PubMed] [Google Scholar]
  • 4.Walsh TJ, Dixon DM. Nosocomial aspergillosis: environmental microbiology, hospital epidemiology, diagnosis and treatment. Eur J Epidemiol. 1989;5:131–142. doi: 10.1007/BF00156818. [DOI] [PubMed] [Google Scholar]
  • 5.Ricket HM, McNeil MM, Edwards MC, Jarvis WR. Cluster of Malassezia furfur pulmonary infections in infants in a neonatal intensive care unit. J Clin Microbiol. 1989;27:1197–1200. doi: 10.1128/jcm.27.6.1197-1200.1989. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Avila MM, Carballal G, Rovaletti, Ebekian B, Cusminsky M, Weissenbacher M. Viral etiology in acute lower respiratory infections in children from a closed community. Am Rev Respir Dis. 1989;140:634–637. doi: 10.1164/ajrccm/140.3.634. [DOI] [PubMed] [Google Scholar]
  • 7.Hall CB, Douglas RG. Nosocomial influenza infection as a cause of intercurrent fevers in infants. Pediatr. 1975;55:673–677. [PubMed] [Google Scholar]
  • 8.Macdonald NE, Hall CB, Suffin SC, Alexson C, Harris PJ, Manning JA. Respiratory syncytial virus infection in infants with congenital heart disease. N Engl J Med. 1982;307:397–400. doi: 10.1056/NEJM198208123070702. [DOI] [PubMed] [Google Scholar]
  • 9.Metlay LA, MacPherson TA, Doshi N, Milley JR. A new iatrogenous lesion in newborns requiring assisted ventilation. N Engl J Med. 1983;309:111–112. doi: 10.1056/NEJM198307143090214. [DOI] [PubMed] [Google Scholar]
  • 10.Groothuis JR, Gutierrez KM, Lauer BA. Respiratory syncytial virus infection in children with bronchopulmonary dysplasia. Pediatr. 1988;82:199–203. [PubMed] [Google Scholar]
  • 11.Influenza Surveillance in England and Wales. 5th ed. Internal publication of the Public Health Laboratory Service; London: 1990. p. 22. (Communicable Disease Report). [Google Scholar]
  • 12.Meilbalane R, Sedmak GV, Sasidharan P, Garg P, Grausz JP. Outbreak of influenza in a neonatal intensive care unit. Pediatr. 1977;91:974–976. doi: 10.1016/s0022-3476(77)80907-4. [DOI] [PubMed] [Google Scholar]
  • 13.White MP, Mackie PLK. Respiratory syncytial virus infection in a special care nursery. Lancet. 1990;i:979. doi: 10.1016/0140-6736(90)91047-e. [DOI] [PubMed] [Google Scholar]
  • 14.Solomon SL, Wallace EM, Ford-Jones EL, Baher M, Martone WJ, Kopin IJ, Critz AD, Allen JR. Medication errors with inhalant epinephrine mimicking an epidemic of neonatal sepsis. N Engl J Med. 1984;(310):166–170. doi: 10.1056/NEJM198401193100305. [DOI] [PubMed] [Google Scholar]
  • 15.Rothman KJ. Sleuthing in hospitals. N Engl J Med. 1985;313:258–260. doi: 10.1056/NEJM198507253130409. [DOI] [PubMed] [Google Scholar]
  • 16.Buehler JW, Smith LF, Wallace EM, Heath CW, Kusiak R, Herndon JL. Unexplained deaths in a children's hospital. N Engl J Med. 1985;313:211–216. doi: 10.1056/NEJM198507253130402. [DOI] [PubMed] [Google Scholar]
  • 17.Istre GR, Gustafson TL, Baron RC, Martin DL, Orlowski JP. A mysterious cluster of deaths and cardiopulmonary arrests in a paediatric intensive care unit. N Engl J Med. 1985;313:205–211. doi: 10.1056/NEJM198507253130401. [DOI] [PubMed] [Google Scholar]
  • 18.Coveler LA, Lester RC. Contaminated oxygen cylinder. Anesth Analg. 1989;69:674–676. [PubMed] [Google Scholar]
  • 19.Kirpalani H, Higa T, Perlman M, Friedberg J, Cutz E. Diagnosis and therapy of necrotizing tracheobronchitis in ventilated neonates. Crit Care Med. 1985;13:792–797. doi: 10.1097/00003246-198510000-00004. [DOI] [PubMed] [Google Scholar]

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