July 12, 2010
More Infection Control Problems At VA Medical Facilities
By Michael D. Shaw
Readers of this column might recall stories we did in April and June of 2009 covering infection control breaches at the Murfreesboro, TN and Miami, FL Veterans Affairs Medical Centers. That case involved issues with colonoscopes, and covered a time span of more than five years.
As a result, nearly 10,000 patients were notified of their possible exposure to HIV, Hepatitis B, and Hepatitis C. An investigation was launched, and another VA facility—at Augusta, GA—was also brought under scrutiny. Detailed reports were released showing that compliance with recommended procedures was well under 50 percent.
We observed at the time that...
Sadly, the problems continue.
The latest breach occurred at the John A. Cochran VA Medical Center in St. Louis, and involved improper procedures for the sterilization of dental instruments. Although the instruments in question were steam sterilized, it was found during a routine inspection in March, 2010 that they were not treated beforehand with detergent. Rather, they were just rinsed.
It is a precept of infection control that a medical device must first be clean before it can be properly sterilized. Ignoring this will virtually guarantee problems.
Thus, on June 28th, a letter was sent out to more than 1800 veterans, advising them that they may have been exposed to the HIV and Hepatitis B and C viruses. Free blood tests are being offered, and the powers that be seem genuinely contrite; that is until you hear what Earline Johnson, a recently terminated Cochran employee who worked in the sterile processing department, has to say.
Johnson claims that she noticed many things being done wrong at the facility, but was ignored when she pointed them out to supervisors—and she has copies of the e-mails and other communications to prove it. She speaks of too many shortcuts being taken and a culture that discourages change.
The hospital explains the three-month delay in notifying patients as necessary to assess the level of risk. But, the June 28th letter states that "Even though it has been determined that there is a low risk of exposure to bacteria or viruses due to this error, we believe any risk to our Veterans is unacceptable."
So, if "any" risk is unacceptable and presumably worthy of patient notification, why would they need to assess the level of risk at all? Perhaps, this assessment included a determination of how many patients could have been exposed, based on when the cleaning problems first started.
Perhaps. But, surely that would not have taken three months.
At least the St. Louis patients got notified, which is a whole lot better than what happened at the Mayagüez outpatient clinic—a satellite of the San Juan, Puerto Rico VA Medical Center.
Back in August, 2009, the VA's Office of the Inspector General (OIG) looked into allegations that transvaginal ultrasound transducer equipment was not being properly disinfected, and that leak tests were not being performed on certain endoscopes. Similar breaches were reported at the main San Juan hospital.
All the allegations would be substantiated, and in March, 2010, OIG called in an outside expert, Dr. Lawrence Muscarella, to evaluate the risk posed by these breaches. Muscarella found that the risk was significant enough to warrant the notification of veterans and other patients of the potential for their exposure to infectious agents. Indeed, such notification is consistent with current VA policy, as demonstrated by the incidents described above, at the other VA facilities.
However, despite Muscarella's findings, the agency concluded that the breach presented a "negligible" risk and no notifications were forthcoming. Bear in mind that the consequences of the Puerto Rico breaches are at least as bad as those in St. Louis, and besides, the VA stated that "any" risk is unacceptable, right?
Representative Bob Filner (D-CA), chairman of the House Veterans' Affairs Committee was positively livid over the St. Louis incident: "It's outrageous, one, that this happens, but even worse is this secretive, almost cover-up mode that they go into when something like this happens."
If Filner thinks that the St. Louis breach qualifies as an "almost cover-up," one wonders what he would say about the Puerto Rico situation.
Needless to say, our veterans deserve better, but then, if this version of government health care is a foreshadowing of what we might expect from so-called Obamacare, so do we all.