It has been nearly 25 years since Philip Rosso Jr.’s mother, Helen, died after being diagnosed with tuberculosis, not long after she received a kidney transplant at Presbyterian Hospital.
But the years have not erased the memory of the four months he watched his mom die.
“It was hell,” said Mr. Rosso, 51, owner of a wholesale glass store in Port Vue. “It was a sad thing to see.”
A study later found that Mrs. Rosso, 59, a mother of nine, had contracted the disease from another patient at Presbyterian. Altogether, six transplant patients contracted TB from each other in a matter of months in 1990 and 1991, and three of them died in the outbreak.
The recent discovery of another deadly outbreak at the same hospital — now known as UPMC Presbyterian — was different from the one 25 years ago: The 2014 and 2015 outbreak at UPMC Presbyterian resulted in two heart patients and one double-lung patient, not kidney patients, being infected by mold, not TB, and two of them died.
But one of the main issues at the heart of what investigators found caused the 1990 and 1991 TB outbreak also was at the center of the more recent mold outbreak: the use of negative pressure in patient rooms.
This raises the question of whether the hospital in the recent outbreak violated guidelines that evolved, in part, from its experience in the prior outbreak.
Because they are taking drugs to prevent their body from rejecting their new organs, transplant patients have a difficult time resisting infection.
Positive pressure rooms are designed to keep potentially infection-containing air out of the rooms, which is why they’re also known as “protective environment” rooms.
Negative pressure rooms — also known as “airborne infection isolation” rooms — are designed to house patients with infectious diseases. They prevent air from inside a room from getting into other patient rooms or corridors inside the hospital. But they allow air from outside to get in.
“Airborne infection isolation rooms are intended to protect the hospital from the patient, while a protective environment room is designed to protect the patient from the hospital,” said Chris Rousseau, a mechanical engineer who chairs an industry committee that oversees guidelines for designing and using such rooms.
The use of negative and positive pressure rooms became a serious issue after a series of similar cases at other hospitals in the 1980s and 1990s. Some hospitals came to see using positive pressure rooms as a good way to protect immunocompromised patients, including transplant patients, from infection.
But UPMC Presbyterian uses “neutral” pressure in all but one of its rooms in its cardiothoracic intensive care unit — where the mold outbreak occurred — and instead tries to cleanse the air coming into the entire area.
Both the Veterans Affairs Pittsburgh Healthcare System and Allegheny General Hospital transplant units also do not use positive pressure rooms and, like UPMC, use special filters to clean all the air in its ICUs.
Using positive pressure rooms “is not a requirement and the benefits though theoretical are not proven,” Brooke Decker, the VA’s infection prevention chief, said in an email.
The findings in the 1993 investigation into the TB outbreak at Presbyterian by the federal Centers for Disease Control and Prevention were so important that they are still cited in the CDC’s current guidelines on using negative pressure rooms.
In 1991, when the outbreak was first identified, Presbyterian thought that all of its rooms in the kidney transplant area were at negative pressure.
But tests by the CDC later in 1991 found that two of the rooms were at positive pressure and two at neutral pressure, including one room where the patient who was the original source of the TB stayed.
“Air flow in buildings fluctuates,” the CDC wrote in its 1993 journal article on the TB outbreak. “Positive relative pressure in the room would have propelled air into the corridor and then into rooms that were at negative pressure. Some contacts could have been exposed in the corridor or communal areas.”
That and several other factors “probably contributed to the outbreak,” the CDC concluded, in addition to a delayed diagnosis of the TB in the patients and a delay in isolating them.
That case put Presbyterian at the center of the discussion on using negative and positive pressure rooms.
In its preliminary report released last month on the recent mold outbreak, the CDC found that UPMC had been using its one negative pressure room in the cardiothoracic ICU to occasionally house immunocompromised transplant patients.
UPMC said it only did that when the ICU was so full there were no other ICU rooms for them to stay in. It also said such a practice was “common” at hospitals with negative pressure rooms — something experts, and other hospitals, disagree with.
Linda Greene, manager of infection prevention at the University of Rochester Highlands Hospital, and several other experts, disagreed.
“In my experience it is not common,” said Ms. Greene, who has worked for 20 years in infection prevention.
The Pittsburgh VA and Allegheny General Hospital said they do not put transplant patients into negative pressure rooms unless they have an infectious disease.
The CDC report found that of the 124 patients who received a heart or lung transplant at UPMC between June 2014 and September 2015, seven stayed in the negative pressure room — but three of those seven patients contracted a mold infection and two of them died.
That is the reason the first of seven changes the CDC recommended to UPMC in its report was that the hospital should “Avoid housing immunocompromised solid organ transplant patients in a negative pressure room unless otherwise indicated.” Under the main theory the CDC is still exploring in the case, the three patients may have been infected when mold spores on a heavily trafficked, carpeted hallway outside the negative pressure room got sucked into the room because of its negative pressure.
So did UPMC directly violate any guidelines for hospitals in letting those heart and lung patients stay in negative pressure rooms?
Tami Minnier, UPMC’s chief quality officer, said in an emailed statement the hospital did not violate any guidelines because UPMC believes the guidelines do not exclude putting transplant patients in negative pressure rooms, and the three transplant patients were not “severely immunocompromised.”
But, she added: “Per the recommendation in the CDC’s preliminary report, we will no longer be placing such patients in these rooms.”
The CDC said in an email that its guidelines do not have explicit recommendations, but it referred to several industry guidelines.
Two of those industry standards, known by their acronyms as the FGI and ASHRAE guidelines, generally describe that patients who need protection from environmental infection should use positive pressure, and patients who need to be isolated because they have an infectious disease should be placed in negative pressure rooms.
Mr. Rousseau, who heads the ASHRAE committee that drew up the most recent revision of the standards, said the decision of where to place patients is “really a medical decision.”
“But the intent of these rooms is to not” place severely immunocompromised patients in isolation rooms. “Each of these rooms is designed for a specific use.”
The third guideline the CDC referred to, from the Association for Professionals in Infection Control and Epidemiology, or APIC, also largely leaves patient placement up to hospitals’ medical decision-making.
Ms. Greene, who is the president-elect of APIC, said “ideally” immunocompromised patients are not placed in negative pressure rooms and she never saw it done in the hospitals she worked in. “Your clinical judgment would lead you to not put such a patient in a negative pressure room.”
Sean D. Hamill: shamill@post-gazette.com or 412-263-2579 or Twitter @SeanDHamill
First Published: January 17, 2016, 5:00 a.m.
