December 12, 2016
Yet More Infection Control Issues At The VA
By Michael D. Shaw
This column has covered infection control problems in healthcare on numerous occasions. (And here, among others.) This subject remains fascinating to me since virtually all such mishaps are preventable, and diligence could save countless lives. However, infection control is a low tech area in the high tech world of healthcare, and gets little respect.
Far too few observers see the irony of a patient being killed by a contaminated life-saving medical device, for want of antiseptic technique—as was introduced by Ignaz Semmelweis in the mid 19th century.
While no healthcare institution is immune from infection control problems, the Department of Veterans Affairs, operating a vast network of clinics and medical centers, has had its share of incidents.
Back in 2009, we covered the matter of tainted colonoscopies that occurred in two or more VA hospitals, resulting in confirmed infections. A five-year window of vulnerability was identified by the agency, prompting them to notify nearly 10,000 veterans that they may have been exposed to HIV, hepatitis B, and hepatitis C.
Given the means whereby these victims were inoculated with pathogens, the above list of possible diseases is far from complete—and only represents a few scary illnesses for which simple tests are available.
But infection control lapses are equal opportunity, and can also occur via the other end, so to speak. The latest chapter in the VA saga involves 592 dental patients at the VA medical center in Tomah, WI (located halfway between Milwaukee and Minneapolis). In the wake of a truly bizarre situation, the rueful victims have been notified that they should be screened for HIV, Hepatitis B, and Hepatitis C.
It seems that an unnamed dentist violated all protocol, and reused his own drill bits, without sterilizing them. Inasmuch as the facility provides him with disposable bits, one can only conclude that he felt more comfortable with his own equipment. Too bad that he didn’t concern himself with the comfort—as in freedom from infection—of his patients.
Alas, it gets worse. Apparently, Dr. X had been doing this since October, 2015, and was finally ratted out a year later, when a substitute dental assistant observed his miserable practices. Thankfully, no infections have yet been determined; and the screening, presumably covering all of his patients, is being done in an abundance of caution. Assistants are now on rotation—don’t you know—so that they are not permanently assigned to a single dentist. No word on why the former assistant didn’t speak up.
A possible explanation is that infection control whistle-blowers are not always treated so well at the VA. There’s the case of lapses in dental sterilization that had occurred from February, 2009 through March 2010 at the St. Louis VA facility. 1,812 veterans were tested for infection, with “some” coming up positive. Medical supply tech Earlene Johnson had been complaining about these problems for months, and was fired for her trouble.
During subsequent Congressional hearings before the Veterans Affairs Committee, representative Jeff Miller (R-FL) said: “The problem I have is every time we have a hearing on one of these incidents, VA says we’ve put in new procedures and controls and it’s not going to happen again. But it happens over and over again.”
In fairness, infection control breaches occur with disturbing regularity at private sector facilities, as well. VA incidents tend to be much more publicized, due to sundry reporting regulations. Mark well, though, that the VA hosts the world’s only healthcare system built from the ground up as a fully socialized medical enterprise. As such, disciplinary procedures against infection control offenders are harder to implement.
Perhaps it is time to remind healthcare workers of the tautology uttered by legendary Harvard physician Francis W. Peabody, during a 1925 lecture on patient care: “For the secret of the care of the patient is in caring for the patient.”