Bed linens filled with mold blamed for deadly crisis in UPMC report
Bed linens supplied to UPMC and possibly hundreds of other health care facilities carried fungus linked to a deadly mold crisis, according to an internal report commissioned by UPMC.
The report, filed Thursday in Allegheny County Court of Common Pleas as part of two ongoing wrongful death lawsuits against the health giant, shows the ventilation system at Paris Healthcare Linen Services blew heavy amounts of fungus onto hospital linens transported to UPMC.
Paris, located about 100 miles northeast of Pittsburgh in DuBois, launders 44 million pounds of laundry every year for 180 customers, including 22 UPMC facilities, the report states. In response to the report, Pittsburgh attorney Brendan Lupetin added Paris as a defendant in both lawsuits.
Five people have died in connection with the mold crisis that was first reported by the Tribune-Review in September 2015. UPMC contends the most recent death was not mold-related.
"We have learned finally what the source of the fungus was that killed all of these patients," Lupetin told the Tribune-Review on Thursday. "Right now we have great concerns on the extent to which remediations have been made to ensure that clean and safe linens are actually being used on the patients at UPMC, specifically the immune-suppressed people."
UPMC issued a statement saying it would not comment on the allegations.
"We continue to be transparent with federal and state health regulators and we shared all our findings with them," Chief Quality Officer Tami Minnier said. "The Centers for Disease Control and Prevention and Pennsylvania Department of Health were unable to determine a definitive source for the fungal infections. Despite the lack of a definitive source, UPMC still went above and beyond state and federal recommendations in order to implement changes to protect our patients."
The changes include using "specially treated bioburden-reduced linens to our highest risk transplant patients," Minnier said in the statement.
UPMC continues to contract with Paris to clean its linens, said UPMC spokeswoman Allison Hydzik. She declined to elaborate.
Lupetin of the Downtown-based Meyers, Evans, Lupetin & Unatin law firm represents families of two organ transplant patients who died during the crisis, Che DuVall and Daniel Krieg. The crisis led to the temporary suspension of UPMC's respected transplant program.
CDC spokesman Tom Skinner said the agency will review the report and "if necessary follow up with the state health department and the medical facility."
While DuVall clung to life at Presby, his lungs riddled with a form of mold called rhizopus, two hospital environmental safety experts hired by UPMC conducted site visits at the Paris laundry facility on Feb. 1, 2016, and Presby and Montefiore the following day. The report identified "heavy fungal growth" on the plant's roof on a lint pile adjacent to the dryer exhaust and intakes.
The report said Paris cools its laundry after drying "by using unfiltered outside air brought in from the roof."
It continued, "After drying, laundry is brought to the clean pack area for ironing and folding to be finally stacked on transport carts."
Andrew Streifel, a hospital environment specialist from the University of Minnesota, authored the report along with Michael Buck, a health and safety compliance specialist at the university.
DuVall, a lung transplant patient, died Feb. 6, 2016, at Presby. Krieg, who had a kidney transplant, died July 9, 2016.
Reached by phone this week, Streifel confirmed the report's existence and declined comment about its contents.
"UPMC is very reputable and good at what they do," he said. "It's unfortunate. Some of the patients are already at end of life."
The report prompted Lupetin to warn Allegheny County Health Department authorities about the linen problem. The letter dated Jan. 24, obtained by the Tribune-Review, asks the county to alert the CDC and state Department of Health.
"We believe that this information demonstrates an ongoing threat to patient safety," Lupetin wrote to Michael Parker, an attorney for the Allegheny County Health Department. "The CDC needs to come back and investigate to determine the full extent of the problem and what can be done to ensure that no more patients needlessly die..."
County health department officials did not comment. State health department officials did not return messages.
Lupetin fears UPMC and others who continue to use Paris are potentially putting thousands of patients with weakened immune systems at risk for harmful infections.
"If nothing is done, it essentially assures that more patients will die prematurely," Lupetin wrote.
It remains unclear why the report, dated May 2, never surfaced after the CDC declared the exact mold source was unknown. The CDC issued two separate reports in connection with the mold crisis. The first, issued Dec. 22, 2015, found "no single source" of fungal infections. The report pointed to ventilation at Presby as a possible source.
On May 13, just 11 days after the Paris report was issued, the CDC published a paper in the Morbidity and Mortality Weekly Report recommending that the ventilation system not be used for patients with weakened immune systems. The so-called "negative pressure" system, which pulls outside air into a room, in some cases "could result in net harm and therefore should be avoided." UPMC agreed and said that practice had ceased.
The May 2 report by Streifel also indicates he and Buck inspected a linen cart delivered by Paris on Feb. 2 at Montefiore.
Samples showed "heavy fungal growth" of rhizopus on the "wet sheets collected from the UPMC laundry carts."
Lupetin said the report is staggering.
"Paris was found to use unfiltered air from outside of their facility to dry their supposedly clean linen," he said.
In November, before the report surfaced, Lupetin filed a subpoena in the DuVall and Krieg lawsuits requesting Paris produce documents related to any mold or fungus testing at its facility on linens supplied to UPMC. He also requested all communications between Paris and UPMC related to the mold crisis.
At that time, the Tribune-Review inquired with Paris about the subpoena.
"Paris Companies is contracted to provide linens at UPMC," the company responded in December through a Pittsburgh public relations agency, Elias/Savion Advertising. "Their representatives visited the facility a few times and found that all protocols were in place to produce hygienically clean linen. In fact, they were quite impressed with the facility and its cleanliness."
In a follow-up response to the Trib, Paris, through Elias/Savion, said: "Paris Companies does not have any results of UPMC's testing. Paris Companies has never found mold from their own internal testing of the linens produced at their facility."
Lupetin was incredulous.
"I can't understand how they don't know about the test results," he said.
A similar fungal outbreak struck a New Orleans children's hospital in 2008 and 2009, killing five child patients.
At that hospital, workers unloaded clean linens on the same dock where medical waste was removed, used the same carts to transport clean and soiled linens and stored linens in hospital hallways covered in construction dust.
That hospital also used an off-site laundry facility.
Jesse Krieg, nephew of deceased transplant patient Daniel Krieg, said he was relieved to get some answers.
"It's not just my uncle that I want justice for," he said. "It's for the donors, the recipients, the families and anyone else who has been affected by this."
Staff writer Theresa Clift contributed. Ben Schmitt is a Tribune-Review staff writer. Reach him at 412-320-7991 or firstname.lastname@example.org.