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Unexplained deaths in a children's hospital. An epidemiologic assessment
Insights
An unexplained rise in infant deaths on a hospital cardiology ward was linked to digoxin toxicity. Most deaths occurred overnight, with a particular nurse’s shifts strongly associated with the fatal events.
Area of Science:
- Pediatric Cardiology
- Hospital Epidemiology
- Clinical Toxicology
Background:
- A significant increase in patient mortality was observed on a pediatric cardiology ward.
- The mortality rate escalated dramatically during a specific nine-month period.
Purpose of the Study:
- To investigate the causes of an unusual epidemic of infant deaths on a pediatric cardiology ward.
- To identify risk factors and potential causes contributing to the increased mortality rate.
Main Methods:
- Comparative analysis of mortality rates before and during the epidemic period.
- Analysis of the timing of infant deaths and clinical presentation.
- Toxicological analysis for digoxin levels in deceased patients.
- Review of nursing schedules to identify potential associations.
Main Results:
- Mortality rate increased from 11.0 to 43.1 deaths per 10,000 patient-days.
- 76% of infant deaths occurred between midnight and 6:00 a.m. during the epidemic.
- Clinical and forensic findings suggested digoxin toxicity in several cases.
- A strong association was found between infant deaths and a specific nurse's duty times (relative risk, 64.6).
Conclusions:
- The epidemic of infant deaths was potentially linked to digoxin toxicity, with unusual timing and clinical patterns.
- While a specific nurse's schedule showed a strong association, the exact cause of the epidemic remains undetermined.
- Recommendations included strengthening medication dispensing controls and implementing a system for monitoring in-hospital deaths.
Abstract:
During a nine-month period, July 1980 through March 1981, the mortality rate for patients on the cardiology ward of a children's hospital was 43.1 deaths per 10,000 patient-days, as compared with 11.0 deaths per 10,000 patient-days during the preceding 54 months. Twenty-five (76 per cent) of 33 infant deaths during this nine-month period occurred between midnight and 6:00 a.m., as compared with 1 of 10 infant deaths during a separate 27-month period (P less than 0.001). Although nearly all deaths occurred in patients with serious congenital heart disease, epidemic-period deaths were more likely to have an unexpected timing and a clinical pattern consistent with digoxin toxicity. In four patients, forensic and clinical digoxin measurements suggested that an intravenous overdose of digoxin had been administered shortly before death. Although a review of nursing schedules revealed a strong association (relative risk, 64.6) between infant deaths and the duty times of a particular nurse, the cause of the epidemic remains unclear. The study led to suggestions that the hospital strengthen central control over procedures for dispensing medicines and implement a system for monitoring the occurrence of deaths by time and place within the hospital.