VA lapses cited in fatal Legionnaires' disease outbreak

Butbecauseofshortcomingsbyitsinfection-control,laboratoryandengineeringandplumbingstaffs,another16monthswouldpassandfourmoredeathswouldbelinkedtotheoutbreakbeforetheVApubliclydeclaredithadaprobleminNovember2012,accordingtointernalVAdocumentsandaVAofficialwhoisnotauthorizedtospeakpubliclyaboutthesituation.
Theoutbreakthateventuallysickened21patients,killingatleastfivepeople,isthefocusofcongressionalandVAinspectorgeneralinvestigations.
AccordingtoVAdocumentsandtheofficial:
•WhenapatienttestedpositiveforLegionnaires'disease,theinfection-controlstaffcheckedforLegionella--thebacteriathatcausesLegionnaires'--onlyinwaterinroomswherethepatientstayed.SeveralexpertssaidthisisinadequatebecauseLegionellacouldbefoundinwatersamplestakenfromotheroutletsofthesamewatersystematthefacility.


PGgraphic:Legionnaires'casesatVA
(Clickimageforlargerversion)
•Inmostcasesearlyintheoutbreak,theVAdidnothaveasampleofthebacteriafromapatient,whichhospitalsgetfroma"sputum"sampleobtainedwhenapatientwithLegionnaires',aformofpneumonia,coughsupmucusfromthelungs.Thoughithadbeenhospitalprotocolasrecentassevenyearsagotoalwaysobtainsputum,suchpracticeswerenolongerrequired.ThatmeansthatevenifthehospitaldidfindaLegionellasampleinthewatersystem,itdidnothaveapatientsampletocompareitto.
•RobertMuder,thechiefofinfectioncontrol,hascomplainedtoVAleadersthathisstaffdidnotdoadditionaltestingbecauseitwasshort-staffedandstretchedthin.TheVAofficialsaysDr.Mudernevermadearequestforadditionalstaff.Dr.Muderdidnotreturnaphonecallseekingcomment.
•Resultsofurineantigentests--theinitialteststhatwoulddetermineifapatienthadLegionnaires'--weredelayedtwoorthreedaysaftertheywereorderedbydoctorsbecausethePittsburghVAlabstaffforefficiencyreasonswaiteduntilithadabatchoffiveormoresamplestotest.Thedelaymayhaveplayedaroleinslowingthemosteffectivetreatmentforpatients.
•BecausethePittsburghVAdidnotregularlyobtainpatientsputumorenvironmentalsamplesforcomparison,anditdidnotdosoevenafterthesecond"probable"caseinviolationoffederalCentersforDiseaseControlandPreventionguidelines,itsinfection-controlstafflackedalltheevidenceitneededtodetermineifaLegionnaires'caseoriginatedinthehospital.Asaresult,infection-controlofficialsconcludedthatthepatientcontractedthediseaseelsewhereanddidn'tlookdeeperintotheproblemuntilthefallof2012,whenitfinallycalledintheCDC.
•Becausetheoriginofcaseswaseitherunknownorruledascomingfromoutsidethehospital,thePittsburghVA'schiefofstaff,AliSonel,didnotknowaboutthreeofthefivecasesinwhichveteransdiedaftercontractingLegionnaires'.ThismayhavepreventedtheVAfromtakingquickeractionearlyintheoutbreak.Dr.Soneldidnotreturnaphonecallseekingcomment.


PGgraphic:Legionnaires'casedetails
(Clickimageforlargerversion)
Despiteallofthesepoints,TerryWolf,directorofthePittsburghVAhealthsystem,believesitsstaffdideverythingitcouldoverthelasttwoyearstogettheoutbreakundercontrol--evenif,inretrospect,itnowwouldhavedonemanythingsdifferently.
"Employeemoraleisreallylowrightnow,andpeoplefearthey'regoingtobefired,"shesaidinherfirstinterviewabouttheoutbreak."Butnobodyshouldhavereasontofeelthey'regoingtolosetheirjob.Wewanttolearnfromthisexperienceandneverletithappenagain."
ShepointstochangesinpoliciesthePittsburghVAhasmadeinthewakeoftheoutbreakandtheproblemsithasuncoveredasevidencethatitisrespondingthewayahealthcaresystemshould.
Testingisnolongerdelayedtowaitforabatchofsamples,andLegionellaculturesandenvironmentalsamplesareobtainedineverycasewhenapatienttestspositive,shesaid.
ButMrs.WolfsaidsheremainsconcernedaboutsomeoftheactionsandstatementsmadebyboththePittsburghVA'sinfection-controlstaff,itslaboratoryanditsplumbingandengineeringstaff,inthefirstfewmonthsoftheoutbreakin2011.
Mostimportant,Mrs.Wolfstillwonderswhythebellsthatfinallywentoffinthefallof2012,whenthePittsburghVAcalledtheCDCintohelp,didn'tgooffinJuly2011,whenthefirstpatient,JohnCiarolla,83,diedaftercontractingLegionnaires'.
"Ihaveaskedthatquestion,"Mrs.Wolfsaid,"andwe'regoingtogettothebottomofit."
TheVA'sinfection-controldepartment,whichischargedwithtestingthePittsburghVA'swaterforLegionella,didnotignoreCiarolla'scase,sheemphasized.
Infact,infectioncontrolwassoworriedabouttheman'spositiveurineantigentestthatMrs.Wolfandherofficestaffputoutan"IssueBrief"onthecaseanditsimplicationsJuly5,2011.
IssueBriefsaresenttotheVA'sregionalofficerunbyregionaldirectorMichaelMoreland.
ThebriefonCiarolla'scasewasthefirstmentiontotheregionalofficein2011thattherewasaLegionnaires'probleminthePittsburghVA--eventhoughatleastonepriorpatient,wholaterrecovered,hadcontractedthediseaseinFebruary2011.
ThatwasthesamemonththattheVA'sUniversityDrivehospitaldetectedanunusualamountofLegionellainitswatersystem.Itfoundthebacteriainsixof16sitesinthehospitalandputthehospital'swatersystemthrougha"heatandflush"procedurethatincreasedthetemperatureofthewaterinthepipestokillmuchofthebacteriaandflushoutwaterforupto30minutesatsitesthattestedpositive.
Follow-uptestinginMarchfoundnopositiveresultsatthehospital.
Butfourmonthslater,Ciarolla,aNavyveteranfromNorthVersailleswhowasaresidentattheVA'sH.J.HeinznursinghomefacilitynearAspinwall,gotsickthelastweekofJune.
Morethaninanyothercase,howCiarolla'sillnesswashandledbythePittsburghVAdemonstratestheshortcomingsthatallowedtheoutbreaktoflourish.
Hisdaughters,MaureenCiarollaofMonroevilleandSharonHeinnickelofGreensburg,saytheirfatherfirstwenttoliveatHeinzsometimeinspring2011becauseofproblemswithdiabetes.Hehadpreviouslybrokenbothhipsandwashavingtroublecaringforhimself.
Hestayedtherefulltime,exceptfordoctorvisitsattheUniversityDrivehospital.HewasdoingsowellthatinJunehisdaughterstookhimoutfortwohalf-dayvisits,June12atMs.Ciarolla'shomeandFather'sDay,June19,atMs.Heinnickel'shome.
OnJune27,JohnCiarollawastransferredtoUniversityDrivebecausehehadafeverandwasdisoriented.Theimmediatediagnosiswaspneumonia,andhewasputonintravenousantibioticsforthreedays,accordingtotheIssueBriefonhiscase.

AurineantigentesttoconfirmthepresenceofLegionellawasdoneJune28.But,becauseofthebatchsystem,thetestwasnotcompleteduntilJuly1anditshowedhehadLegionnaires'.
TheCDCreportsaysdoctorsnevergotasputumsamplefromCiarolla.AndthoughtheIssueBriefsaidtheVA'sinfection-controlstaffattemptedtogetanenvironmentalculturefromHeinz,itonlytriedtogetasamplefromroomswherehestayed,accordingtotheVAofficial,andapparentlyfoundnoLegionellathere.
That'salsowhatRonVoorhees,interimdirectoroftheAlleghenyCountyDepartmentofHealth,saidhewastoldwhenheaskedabouttheVA'sLegionnaires'casesin2011.TheVAsaid"alltheirenvironmentalsampleswerenegative."
Withnoenvironmentalorsputumsamplestoreview,theVA'sinfection-controlteamturneditsattentiontothehalf-dayvisitstohisdaughters'homes.TheywerebothaskedtotakewatersamplesandsendthembackintotheVAfortesting.
"Ifelttooguiltytoevensendthemin,"Ms.Ciarollasaid."Ididn'twanttoknowifhegotsickatmyhousethesamewaytheVAdidn'twanttoknowifhegotsickintheirbuildings."
AfterherfatherdiedonJuly18,2011,oneofJohnCiarolla'sdoctors,GillesClermont,listedhisprimarycauseofdeathas"septicshock,"withasecondarycauseas"pneumonia,"butnomentionofLegionnaires'.Dr.Clermontdidnotreturnacalloremailseekingcomment.
AttheCongressionalhearingontheoutbreakFeb.5inWashington,D.C.,thefamilyofWilliamNicklas,87,thelastofthefiveveteranstodieduringtheoutbreak,saidMs.Ciarollaapproachedeachofthemandapologizedfornotdoingmoretofindoutwhathappenedtoherfather.
"Ihadtoapologizetothem,"Ms.Ciarollasaidrecently."IfIhadn'tfeltsoguilty,maybeIaskmorequestionsandmaybetheyfigurethisoutthenandmaybethoseotherfourveteransdon'tdie.That'swhyI'mnotlettingthisgonow."


Readmore:http://www.post-gazette.com/stories/local/neighborhoods-city/va-lapses-cited-in-fatal-legionnaires-disease-outbreak-676079/#ixzz2Lq2MWYle


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