VA Pittsburgh leaders blame flawed testing, other factors for Legionnaires' outbreak
The Legionnaires' disease outbreak at VA Pittsburgh Healthcare System hospitals resulted from “flawed” testing procedures and the “deadly myth” that there's a safe level of the bacteria, the chief of staff, Ali Sonel, said on Monday.
Dr. Sonel said officials at other Western Pennsylvania hospitals told him at a regional Legionella bacteria task force meeting that they have been operating with those same flawed procedures, though he declined to name the hospitals. The government and media investigations, congressional hearings and public criticism that resulted from the VA Pittsburgh's announcement of its deadly outbreak make it less likely those hospitals will come clean if they find their own outbreak, he said.
“They don't want to go through that. They would rather try to fix it internally,” Sonel said.
Representatives for West Penn Allegheny and UPMC health systems — which own most Pittsburgh-area hospitals — said their facilities follow comprehensive Legionella monitoring and prevention policies.
The House Veterans Affairs Committee held a hearing on Sept. 9 Downtown at which members criticized the VA's lack of openness about the outbreak, which the Centers for Disease Control and Prevention said lasted from February 2011 to November 2012.
At least 21 veterans were sickened, and at least five of them died.
Sonel declined to comment on specific cases but said in some of the five deaths the primary cause might have been a medical condition other than Legionnaires' disease.
“We figured they were going to try to find anything to say it wasn't the Legionnaires',” said Judy Nicklas, daughter-in-law of William Nicklas, who entered the VA Oakland hospital after officials were told by the CDC they had an outbreak and died shortly after they announced those findings publicly. Nicklas' family is among those suing the VA over the outbreak. “All I know is, my father-in-law walked into that hospital on his own two feet.”
The outbreak at the VA Pittsburgh hospitals in Oakland and O'Hara came to light because of the VA's testing, said VA Pittsburgh CEO Terry Gerigk Wolf.
“We just test way more than anyone else does,” Wolf said during a briefing for reporters on the progress made since the outbreak. Congressional staff were briefed earlier in the day.
Media photographers were not permitted at the “open house.”
Dr. Robert Petzel, a VA undersecretary who oversees all veterans' health care facilities under the Veterans Health Administration, pointed to higher than average Legionnaires' disease cases in Allegheny County during the hearing earlier this month. The Tribune-Review detailed those higher levels in a February story, and also reported previously that water samples as far back as 2007 at VA Oakland showed high concentrations of Legionella bacteria.
“The situation at the Pittsburgh VA revealed a failure to report and a failure to put in place policies that protect veterans from disease outbreaks,” said Sen. Bob Casey Jr., D-Scranton, who will vote on Petzel's successor. “I'll be specifically asking the next undersecretary to implement portions of my bill that would require the VA to report infectious disease outbreaks to the appropriate local health officials.”
Such reporting is among the steps the VA Pittsburgh voluntarily took after the outbreak, in addition to increasing the size of water samples to the CDC-recommended liter, up from the 10th of a liter required by national VA guidelines. The hospital system hired Phigenics, an Illinois-based water management company, to test its 3,000 water fixtures for temperature, acidity and more.
Phigenics technicians upload test results instantly to a database, which analyzes the numbers and sends out warnings if the levels are off, said Tony Dallmier, the company's regional manager.
Poor record-keeping and low disinfectant levels were among the causes of the outbreak cited by a VA Inspector General report released in April.
More work remains, VA officials said. The VA plans to finish mapping its plumbing system by the end of December, after which it will choose a permanent Legionella prevention system or, more likely, a combination of systems, Sonel said.
Currently, the VA Pittsburgh relies on a combination of regular hot water and chlorine flushes, both of which can damage aging pipes.
“We are entertaining other options,” Wolf said. She declined to address why these steps weren't taken before or during the outbreak.
“I'm trying to move forward in Legionella control, to be the best, because that's what VA Pittsburgh does,” Wolf said. “I'm sorry for the loss of veterans and anyone who got sick, but the only thing I can do as the leader of this organization is to make it better and to make sure that nobody gets this again.
“They will. Somebody will. I rue that day.”
Mike Wereschagin is a staff writer for Trib Total Media. He can be reached at 412-320-7900 or firstname.lastname@example.org.
The VA announced on Friday that Dr. Robert Petzel, a VA undersecretary who oversees all veterans' health care facilities under the Veterans Health Administration, will retire next year, saying the retirement had been planned. A national VA spokesman did not respond when asked whether congressional and public criticism factored in his departure. The announcement of Petzel's retirement occurred just days after the Trib reported that Petzel had steered a VA consulting contract for training to a friend and former VA colleague.