Mix-up Involving Hydraulic Fluid-Washed Instruments Still Raising Concerns

Even as infection control practitioners, risk managers and surgeons wonder about the implications of the use of surgical instruments cleaned by mistake with elevator hydraulic fluid, a story released by the Associated Press (AP) on June 13 is fanning the flames of controversy and concern. In an update of last years events, the AP said that a new report by the Centers for Medicare & Medicaid Services (CMS) charged that Duke Health Raleigh and Durham Regional hospitals put patients in immediate jeopardy in November and December by not detecting the problem, despite complaints from medical staff about slick tools.

It was originally reported that two surgeons at two North Carolina hospitals used surgical instruments that were cleaned with hydraulic fluid instead of detergent, a mistake that affected approximately 3,800 patients. In late 2004, elevator technicians at Duke Health Raleigh Hospital and Durham Regional Hospital, part of the Duke University Health System, had allegedly drained hydraulic fluid into empty detergent containers without changing the labels. Soon after, surgical staff reported that some of the surgical instruments felt slick, but it was several months later when it was revealed that for two months, surgeons had been unwittingly using instruments that had been decontaminated and washed in the fluid. News reports indicated that the instruments had been steam-sterilized. It was also reported that upon discovery of the situation, Duke University Health System assured patients that the mix-up created little chance of medical problems. According to the AP, the hospitals monitored infection rates and found no increase for the time the hydraulic fluid was used; however, the CMS report claims that both hospitals had endangered patients.

The AP also reported that a spokeswoman from the Duke University Health System has said that both hospitals have created plans to prevent such problems in the future. The AP added that this week, a regional attorney is claiming that a number of former patients have contacted him, complaining of aching joints and infections. In late April 2005, the News & Observer newspaper, serving Durham County in North Carolina, reported that a second lawsuit had been filed, stemming from the hydraulic fluid mix-up. The newspaper reported that both lawsuits had been filed against the elevator company and the medical supply distributor, and not Duke. The second suit was being brought by a group of seven women, each of whom says she has experienced complications since having surgery at the hospitals where the mix-up occurred. The newspaper reported that spokespersons for the hospitals, the elevator company, and the medical supply company have not commented on the lawsuits.

Documents obtained today from the North Carolina Department of Labors Division of Occupational Safety and Health, reveal that on March 29, 2005, state investigators issued citations for non-serious violations of occupational health and safety.

The citation reads, The employer did not ensure that each container of hazardous chemicals in the workplace was labeled, tagged or marked with the identity of the hazardous chemical(s) contained therein. Item 1a reports that subcontracted employees of Automatic Elevator Company, Inc. used 10 15-gallon plastic drums labeled Mon-Klenz (detergent) for storage of hydraulic fluid (flammable). Item 1b further reads that the 10 15-gallon plastic drums labeled Mon-Klenz (detergent) actually contained hydraulic fluid (flammable) drained from the Duke Health Raleigh Hospital facilitys parking lot elevators by sub-contract Automatic Elevator Company, Inc.

The citation stated that, The employer did not develop, implement, and/or maintain at the workplace a written hazard communication program which describes how the criteria specified in 29 CFR 1910.1200(f)(g) and (h) will be met in a facility where employees use chemicals, including but not limited to hydraulic fluid and oil, for equipment repair and refurbishing.

The citation also stated that, Employees were not provided information and training as specified in 29 CFR 1910.1200(h)(1-2) on hazardous chemicals in their work area at the time of their initial assignment and whenever a new hazard was introduced into their work area. The North Carolina Department of Labor explains in the citation that a written hazardous communication program incorporates an updated list of all hazardous chemicals known to be present, using an identity that is referenced on the material safety data sheet; labels and other forms of warning for each container of hazardous chemicals in the workplace; maintenance of copies of the required MSDS for each hazardous chemical in the workplace; and employee information and training.

The Agency for Toxic Substances and Disease Registry (ATSDR), Division of Toxicology, located in Atlanta, reports that exposure to hydraulic fluids occurs mainly in the workplace, and that drinking certain types of hydraulic fluids can cause death in humans, and swallowing or inhaling certain types of hydraulic fluids has caused nerve damage in animals. It also reports that contact with some types of hydraulic fluids can irritate skin or eyes. The agency also says that these substances have been found in at least 10 of the 1,428 National Priorities List sites identified by the Environmental Protection Agency (EPA). The ATSDR explains on its Web site that hydraulic fluids are a large group of liquids made of many kinds of chemicals and  are used in automobile automatic transmissions, brakes, and power steering; fork lift trucks; tractors; bulldozers; industrial machinery; and airplanes. The three most common types of hydraulic fluids are mineral oil, organophosphate ester, and polyalphaolefin.

According to material from the ATSDRs Web site, Little is known about how hydraulic fluids can affect your health. Since hydraulic fluids are actually mixtures of chemicals, some of the effects seen may be caused by additives in the hydraulic fluids. In people, the effects of breathing air with high levels of hydraulic fluids are not known. Drinking large amounts of some types of hydraulic fluids can cause pneumonia, intestinal bleeding, or death in humans. Weakness of the hands was seen in a worker who touched a lot of hydraulic fluids. Rabbits that inhaled very high levels of one type of hydraulic fluid had trouble breathing, congested lungs, and became drowsy. The nervous systems of animals that swallowed or inhaled other hydraulic fluids were affected immediately with tremors, diarrhea, sweating, breathing difficulty, and sometimes several weeks later with weakness of the limbs, or paralysis. The immediate effects are caused because hydraulic fluids stop the action of certain enzymes, called cholinesterases, in the body. There are no reports of people swallowing or breathing the types of hydraulic fluids that cause these effects. When certain types of hydraulic fluids were put into the eyes of animals or allowed to touch the skin of people or animals for short periods of time, redness and swelling occurred. It is not known whether hydraulic fluids can cause birth defects or reproductive effects.

When asked to comment, Jeffrey Engel, MD, a North Carolina state epidemiologist, remarked, "From my perch here at the state level -- and I might not have my ear to the ground like a local infectious diseases doctor may -- we have not had any reports of any increase (in infection rates), beyond what we would normally expect, in the patients who were exposed to hydraulic fluid.

Requests for official comment from the Duke system and other experts were not immediately responded to for this article.