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Highlights of the VA inspector general report on Pittsburgh Legionnaires' outbreak

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By Luis Fábregas and Adam Smeltz
Wednesday, April 24, 2013, 12:01 a.m.
 

A report by the Veterans Affairs Office of the Inspector General issued on Tuesday found the Pittsburgh VA Healthcare System did not follow its guidelines in combating the deadly Legionella bacteria.

An outbreak of the bacteria from February 2011 and November 2012 has been linked to 21 cases of Legionnaires' disease. Five veterans died.

Key findings in the Inspector General report:

• Inadequate maintenance at all times of a copper-silver ionization system designed to prevent Legionella bacteria in the water systems at the Oakland and O'Hara campuses. There were multiple instances of low copper levels in the system, a key solution in the water treatment system.

• Failure to conduct routine flushing of hot water faucets and showers, especially in infrequently used areas that would allow Legionella bacteria to develop and expand.

• Failure to test all patients with hospital-acquired pneumonia for Legionella, as recommended by VA guidelines for facilities with transplant centers. In September 2011, even though Legionella had been identified in environmental samples, only seven of 17 patients with hospital-acquired pneumonia were tested for Legionnaires'.

• Inconsistent communication and coordination between departments at the VA. The pathology and laboratory medicine service and facilities management service staff did not submit required reports to the infection prevention team.

• Responding to positive Legionella cultures by flushing outlying waterline outlets at normal hot water temperatures, a corrective action not consistent with Centers for Disease Control and Prevention or Veterans Health Administration guidelines recommending superheated flushing.

• Failure to test all patients with hospital-acquired pneumonia for Legionella, as recommended by VA guidelines, even after the outbreak became public and the chief of medical staff had ordered it.

The Inspector General's report is released weeks after an ongoing Tribune-Review investigation reported these issues and other problems with VA practices and actions that contributed to the outbreak. Among the Trib's findings:

• Inadequate testing requirements by the VA Pittsburgh resulted in water samples that were one-tenth as large as the CDC recommends for proper screening of the Legionella bacteria in the hospitals' water systems.

• A worker for the outside contractor that built the VA's Legionella prevention system told his boss that, on a site visit in early 2012, he saw a VA worker falsifying records about the system's upkeep.

• Lovetta Ford, the VA Pittsburgh official in charge of facilities management and the Legionella prevention systems, was hired in the early months of the outbreak. She lacked the engineering and science background of colleagues in similar positions in other VA hospitals.

• A loophole in state and federal laws does not require mandatory reporting of Legionnaires' and other infectious diseases to the CDC and state and county health officials.

• The hospital should have known the perils of lax Legionnaires' screening better than most facilities because it was the site of a major outbreak from 1979 to 1982 that sickened more than 100 and killed about 30 people. The bacteria found in the recent outbreak was “almost identical” to a bug found there in 1982, suggesting it survived in the hospital's water system for decades, the CDC said.

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