Highlights of the VA inspector general report on Pittsburgh Legionnaires' outbreak
By Luis Fábregas and Adam Smeltz
Published: 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.
Show commenting policy
TribLive commenting policy
You are solely responsible for your comments and by using TribLive.com you agree to our Terms of Service.
We moderate comments. Our goal is to provide substantive commentary for a general readership. By screening submissions, we provide a space where readers can share intelligent and informed commentary that enhances the quality of our news and information.
While most comments will be posted if they are on-topic and not abusive, moderating decisions are subjective. We will make them as carefully and consistently as we can. Because of the volume of reader comments, we cannot review individual moderation decisions with readers.
We value thoughtful comments representing a range of views that make their point quickly and politely. We make an effort to protect discussions from repeated comments either by the same reader or different readers.
We follow the same standards for taste as the daily newspaper. A few things we won't tolerate: personal attacks, obscenity, vulgarity, profanity (including expletives and letters followed by dashes), commercial promotion, impersonations, incoherence, proselytizing and SHOUTING. Don't include URLs to Web sites.
We do not edit comments. They are either approved or deleted. We reserve the right to edit a comment that is quoted or excerpted in an article. In this case, we may fix spelling and punctuation.
We welcome strong opinions and criticism of our work, but we don't want comments to become bogged down with discussions of our policies and we will moderate accordingly.
We appreciate it when readers and people quoted in articles or blog posts point out errors of fact or emphasis and will investigate all assertions. But these suggestions should be sent via e-mail. To avoid distracting other readers, we won't publish comments that suggest a correction. Instead, corrections will be made in a blog post or in an article.
- Pa. auditor general DePasquale warns of ‘red flags’ in state’s road bill
- Schmotzer says he got things done in Baldwin-Whitehall job
- Newsmaker: Dr. Susanne Ahmari
- Pittsburgh Poison Center warns of krokodil
- Veterans’ wait for World War II memorial to end soon with dedication of North Shore monument
- Smaller transit service funds intact under new Pa. transportation plan
- Nation increasingly at odds over use of ‘God’
- Video exalted as interrogation tool for police officers
- Addiction ‘epidemic’ concerns Wecht
- Pittsburgh-area Big Brothers program short on male mentors
- Nonprofits’ fiscal issues investigated by state Attorney General Kane