Investigation of VA Medical Center Infection Control Breaches Continues

In the wake of the discovery that as many as 1,800 veterans may have been exposed to HIV and the hepatitis B virus while receiving dental care at the John A. Cochran Medical Center in St. Louis, an independent panel is now investigating why there were breaches of infection prevention and control practices relating to the disinfection and sterilization of instruments. In a statement, the Department of Veterans Affairs noted, "The St. Louis facility has undergone a thorough examination, and many safeguards are in place that are designed to prevent a similar situation from occurring again. In-depth staff training and management reviews were immediately conducted by the St. Louis leadership, medical staff, and VAs Supply, Processing and Distribution (SPD) program office teams."

According to St. Louis Post-Dispatch reporter Phillip O'Connor, the three-member investigative panel is expected to complete its work within 60 days. O'Connor adds that the panel will "interview witnesses and conduct a complete review to determine the reasons for the failure to follow correct procedures. The panel also will make recommendations to prevent another occurrence."

Veterans Affairs sent letters to 1,812 veterans to notify them that they may have been infected with the hepatitis B and C viruses, as well as HIV, from improperly cleaned dental equipment. According to O'Connor, "The warning touched off an outcry, prompted congressional scrutiny and led to the chief of the dental clinic being placed on leave." O'Connor reports further, "The breakdown at Cochran, according to the VA, happened during the prewash of dental instruments. A detergent is supposed to be used during the washing process, before an instrument such as a dental pick is put into a sterilizer. The instruments were rinsed, but no cleanser was used. The instruments, though, did go through heat sterilization, which is thought to kill all microorganisms, including the viruses in question. The lapse was discovered in March in a routine inspection by an infection control team. The VA needed time to review the information, identify patients and study the scope of the problem before it could notify veterans, officials said."

The House Committee on Veterans' Affairs scheduled a hearing for July 13 in St. Louis to investigate the infection control lapses, and attendees include affected veterans, acting director of the Cochran VA center RimaAnn Nelson, representatives from veterans organizations and the Department of Veterans Affairs, as well as Earlene Johnson, the former Cochran employee who has produced e-mail evidence that she told a supervisor about problems with the dental equipment sterilization process as early as August 2009 -- six months before the VA addressed the problem.

Missouri Congressman Russ Carnahan noted, "The stories I have heard from veterans since this issue came to light are deeply disturbing," Carnahan said. "These veterans want and deserve answers, and I intend to get them."

Carnahan says that shortly after news of the breaches broke, he spoke by phone with VA Secretary Eric Shinseki, expressing his anger about how veterans were being treated and reiterating his demand that the VA immediately investigate this breach of standard operating procedures, report back on what will be done to remedy the issue, and ensure that it never occurs again.

Carnahan said that any investigation must include a thorough exploration regarding internal emails that indicate that a staff member at the Cochran dental clinic reported problems with the equipment sterilization process as long ago as August 2009. The staffer in question was terminated in November of 2009 -- just over two months after raising concerns about the sterilization process. "Why did it take the VA almost six months to address this problem?" Carnahan asks. "Why was this staffer ignored, and then fired just two months later? And why did it take almost four months to notify the veterans affected by their mistakes?"

Carnahan spoke by phone with several area veterans who have received letters from the VA, indicating that they may be a risk of contracting hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV) infection. Several veterans have indicated that even as they have tried to set up appointments with the clinic for blood tests, they have been treated poorly and given little information.

"I am appalled at how our veterans are being treated, and I told Secretary Shinseki so," Carnahan says. "Some of these vets have serious health issues and combat-related injuries and stress disorders. This is not how they deserve to be treated."

Carnahan also held a conference call with members of his Veterans' Advisory Panel, comprised of vets from throughout the region, asking them to proactively reach out to veterans and family members in their communities to identify what assistance is needed and whether they have encountered problems getting information or appropriate care. --

Missouri Sen. Claire McCaskill was unable to attend the July 13 hearing, but she submitted the following testimony that was presented at the meeting: "As we all now know, approximately 1,812 St. Louis-area veterans were potentially exposed to blood-borne pathogens, including hepatitis B and C and HIV, as a result of possibly being treated with improperly cleaned dental devices at the John Cochran VAMC dental clinic between February 2009 and March 2010. I know that I -- and I would venture to say all Americans -- were deeply saddened and disappointed by this revelation. My colleagues Senators Bond and Durbin and I made that clear in our June 30, 2010 letter to Veterans Affairs (VA) Secretary Eric Shinseki, which I am providing today and request that you include in the record of this hearing. Veterans are our nation's heroes -- men and women who risked their health and safety for our freedom -- and it is disturbing to learn that their health and safety could have been endangered in any way, even if by accident. As we all know, such mistakes simply cannot be allowed to happen. In addition, our veterans' trust and confidence in the VA medical system and, particularly in the John Cochran VAMC, is badly damaged by incidents like this one. It is going to take time to get that trust back, but I believe the VA can and must do so, and I know today's hearing will be part of that process.

McCaskill's testimony continues, "We all agree that veterans receiving treatment at John Cochran deserve the best quality care available, including absolute assuredness that the hospital is meeting the most basic and critical professional standards of cleanliness and conduct. This one incident is disturbing enough, but unfortunately John Cochran VAMC has been the source of other violations and low customer service ratings in the past. In April 2010, the VA Inspector General released a report outlining reprocessing problems with endoscopes used at John Cochran VAMC. Prior to that, John Cochran received some of the lowest customer service satisfaction ratings of any VAMC in the country. I know that efforts have been made to address these problems by the VA, but the latest revelations about the improper dental device sterilization pose a significant setback to progress.

Further, many veterans groups have expressed concern to me about John Cochran VAMC, including the Paralyzed Veterans of America Gateway Chapter, which has strongly opposed a move of the spinal cord treatment unit to John Cochran VAMC. I have written to Secretary Shinseki about this move because I understand their concerns. I ask that the letter to Secretary Shinseki also be included in the record of this hearing. I am also deeply concerned that the VA took four months (from March until the end of June 2010) to notify veterans who may have been endangered by the flawed procedures at John Cochran VAMC, as well as to notify the area Congressional delegation so that we might assist our constituents, many of whom have called my office worried and outraged about this incident. I appreciate that the VA acted quickly to remedy the flawed cleaning procedures, but the failure to share information in a timely fashion about the situation is unacceptable. In addition, a follow up visit to John Cochran VAMC by VA headquarters staff was not conducted until May 2010, some two months after the initial inspection revealed problems with the cleaning of the dental devices. When a significant failure in procedures occurs, like those discovered at the John Cochran VAMC dental clinic, I would expect a more timely response and more aggressive oversight. There must be an evident and palpable sense of urgency from the VA. It is clear the VA now has such a sense of urgency and it must continue."

McCaskill continues, ""The VA has decided to dedicate $5 million in funding to make infrastructure and other improvements at the John Cochran VAMC in light of this troubling incident. While I applaud the VA's efforts to address aggressively underlying problems, including infrastructure problems that could have contributed to the failures in the dental clinic, I and the other members of the Missouri and Illinois delegations want to be kept closely apprised of how the $5 million in renovations will be prioritized and spent. I ask today that the VA keep me, the rest of the congressional delegation and all interested veterans and veteran service organizations, regularly informed about any follow up actions that the VA takes to train staff and improve standard operating procedures in the dental clinic and elsewhere in the hospital. As John Cochran VAMC staff go about the task of evaluating each of the 1,812 veterans who have received letters from the VA about potential exposure from improperly handled dental devices, I ask for a full and complete accounting by the VA of any health irregularities identified and attributed to the exposure -- I cannot stress enough how any exposure would be a truly tragic outcome to this case. I know that Secretary Shinseki and the staff at John Cochran VAMC value the health and safety of each and every veteran, and I strongly urge him and the John Cochran VAMC leadership to make sure that no veteran's health goes unchecked in this exposure case. The incident at John Cochran VAMC is a sad chapter that leaves a stain on the VA system. I abhor that it happened, and I join the Committee and all Americans in demanding a full accounting and assurance that such an incident will not happen again. Because of the challenges John Cochran VAMC has continued to face, I also call for a redoubling of efforts to make improvements at the facility."