Star-ledger Editorial, published by NJ.com.
In a committee room in Trenton today, a group of lawmakers, hospital administrators, infection experts, and the commissioner of the Department of Health will try to untangle the mystery that took the lives of 14 medically-fragile children and infected dozens more in two long-term facilities over the last few months.
At the Wanaque Center for Nursing and Rehabilitation, 11 children died and 34 others have fallen ill from the common adenovirus, which can be life-threatening to those with severe disabilities or compromised immune systems.
At University Hospital in Newark, three premature infants died in the neonatal intensive care unit after a bacterial outbreak.
The root cause analysis from the Health Department is still weeks away, and we may never learn whether the culprit was human failure or tragic happenstance at either facility.
But when they meet before the Senate Health Committee chaired by Sen. Joe Vitale, one thing must happen: They have to agree that when the most vulnerable lives are at stake, there cannot be any acceptable margin for staff error – and that doesn’t always seem to be the case at either facility.
The Legislature needs to take an especially close look at the University Hospital, which has been under intense scrutiny from DOH Commissioner Dr. Shareef Elnahal for months.
He admits to having “concerns” about whether UH has followed proper infection protocols, and when Elnahal sent a survey team to the hospital Tuesday, it learned that UH’s own infection control program “was not even aware” that two children had died the week before. A state-run teaching facility should not have such systemic problems, but it is sadly predictable.
It is a reminder that UH’s last grade from the venerable Leapfrog Group – the transparency advocate that assesses hospitals on avoidable errors, injuries and infections, which studies say kill 500 people every day in the U.S. – was a D.
It was the second-lowest Leapfrog safety rating given to a New Jersey hospital during the Fall 2018 term. Leapfrog has high standards, and participation is voluntary, but 67 hospitals were graded, and 54 of them were rewarded with an A or B.
“Quality measures seem esoteric,” says Linda Schwimmer, president of the New Jersey Health Care Quality Institute, “but they highlight the importance of transparency, particularly with regard to posting a hospital’s infection rate.”
Vitale (D-Middlesex) is more blunt: “Real leadership creates and reinforces a culture of safety and excellence,” he said. “It is woefully lacking at UH.”
Wanaque’s reputation, meanwhile, is not sterling in all areas. The Centers for Medicare and Medicaid Services uses a five-star grading system based on on-site inspections, with 1,500 standards reviewed. And while Wanaque’s overall rating was 4 out of 5 in its last assessment, CMS gave it a 2 for health inspection.
So this is a chance to re-examine protocols and determine where lapses may exist. Health industry experts tend to think that new requirements bring normal hospital functions to a screeching halt, but it is crucial for Vitale’s committee to determine whether the state needs to be granted more authority to enforce these protocols.
It’s true that the Health Department may not be able to pinpoint the origin of these infections and the insidious pattern by which they spread. It is possible that they were the lethal link in a chain of unfortunate events perpetuated by a single employee making a tragic mistake.
But we are certain of this: Children died, and we are obligated to seek solutions. There is no other way to honor the loved and the lost, now linked in our collective memory as a divine kinship, forming a sacred ring of eternity. They deserve our best.