Report spreads blame for VA Legionnaires' disease outbreak
Systemic failures at the VA Pittsburgh Healthcare System allowed a deadly Legionnaires' disease outbreak to fester, even as leaders believed they were solving the problem, a Tribune-Review analysis of a report by the Veterans Affairs Office of Inspector General found.
The scathing report issued last week showed the hospital system paid scant attention to the importance of water temperature in killing the deadly Legionella bacteria. No one from the facilities management team actively belonged to the infection control team, and local VA officials failed to test some patients with pneumonia for Legionnaires' disease.
The outbreak lasted from February 2011 through November 2012, according to the Centers for Disease Control and Prevention.
“When something bad happens, I take ultimate responsibility,” Pittsburgh VA director and CEO Terry Gerigk Wolf told the Trib.
The 34-page report, however, indicates there's plenty of blame to spread among VA Pittsburgh management and its overseer, VISN4 regional director Michael Moreland.
Though the VA inspector general report mentions no names in assigning responsibility to individuals, it describes by position or area a series of failures by Wolf and other administrators. In addition to Wolf, senior managers during the outbreak included Chief of Staff Ali Sonel and Associate Director Lovetta Ford.
The investigation found problems in key areas:
• Inadequate management of the special water treatment system intended to keep deadly Legionella bacteria from thriving. The report cited “lack of clarity” about what was done to correct problems and even about the definition of the phrase “heat and flush.” At one point, workers flushed some of the 2,700 water outlets at usual hot water temperatures and without hyperchlorination, which is not accepted practice and cannot eradicate the bacteria.
• Facilities management at the VA Pittsburgh falls under the responsibilities of Ford, a former social worker whose education degrees list no background in science, medicine or business.
• The failure to test for Legionnaires' in all patients believed to have contracted pneumonia while hospitalized, as required by 2008 guidelines issued by the Veterans Health Administration. Medical decisions for dealing with Legionnaires' are the responsibility of Sonel, in concert with the duties of infection control chief Robert Muder. Sonel told the Trib that “in hindsight,” VA patients at the Oakland and O'Hara hospitals should have been tested for the disease.
• Lack of communication between those in charge of facilities management and those in charge of infection control. The facilities management team only became “active members” of the Legionnaires' remediation and infection control committee in January. The VA has begun a water safety committee that intends to meet twice monthly under the leadership of Ford, whose oversight of the water system during the outbreak the report sharply criticizes.
“The biggest deficiency that the VA made was a failure to protect the patient when they knew Legionella had re-entered the drinking water,” said Legionella researcher Dr. Victor Yu, who built a well-known pathogens laboratory at the VA Pittsburgh before then-director Moreland dismissed him and closed the lab in 2006. Moreland approved the destruction of a collection of thousands of Legionella bacteria strain samples from around the world.
Moreland, who preceded Wolf as director of the Pittsburgh VA, declined interview requests. VA national spokesman Mark Ballesteros would not address specific questions about the report. He emailed a prepared statement repeating previous statements about the VA's commitment to safety and quality for patients.
Moreland, who oversees most of Pennsylvania's VA facilities and parts of those in four other states, “has got to take responsibility” for what happened at the VA Pittsburgh system, said Ward Morrow, general counsel of the American Federation of Government Employees, a Washington-based union that represents about 2,500 workers at Pittsburgh VA.
The union has urged VA Secretary Eric K. Shinseki to open a full investigation of Moreland's leadership.
“We're concerned about what appears to be a culture of cronyism with Michael Moreland and promotions of people who are loyal to him, as opposed to promotions for competence,” Morrow said.
The VA's inability to eradicate Legionella by flushing pipes with standard hot water, as spelled out in the inspector general's report, is no surprise to Janet Stout, a microbiologist in the VA lab and Yu's research partner. Such a method merely allows Legionella to fester, according to research trials in the 1980s. Water instead must be superheated.
In a response to the inspector general's findings published with the report, Wolf said the plumbing system at the VA Oakland hospital could not support prolonged higher temperatures.
Stout said that likely refers to engineering limits, but noted, “Most of them can be overcome.”
“I have tremendous concern over the people who were making the decisions that got the Pittsburgh VA into the situation where they are,” said Stout, who resigned from her position at the VA in 2007 and runs an Uptown lab.
Moreland's decision to shutter Yu's lab prompted a congressional hearing in 2008 in which the subcommittee's chairman, Rep. Brad Miller, D-N.C., criticized Moreland's leadership and questioned his honesty. A Feb. 5 congressional hearing about the Legionnaires' outbreak marked the second time the government probed Moreland's actions.
“We need to take a look and see why the people who did this are still in management,” Morrow said.
Wolf told the Trib no one has asked her to step down. She and Moreland on Thursday met with a bipartisan delegation of U.S. House members, including Republicans Tim Murphy of Upper St. Clair and Keith Rothfus of Sewickley, and Democrat Mike Doyle of Forest Hills.
A congressional subcommittee asked for — but has not received — key VA documents and emails from 2007 to the present related to the Legionnaires' disease outbreak.
“It's bad enough that department officials won't explain why VA Pittsburgh Healthcare System executives received significant performance bonuses as the outbreak spread,” said Rep. Jeff Miller, a Florida Republican who chairs the House Committee on Veterans' Affairs.
“What's even worse is that the department continues to drag its feet in providing crucial information that would help the victims of this tragedy and Congress understand exactly what happened.”
Luis Fábregas, Adam Smeltz, Mike Wereschagin and Lou Kilzer are Trib Total Media staff writers. Reach Fábregas at 412-320-7998 or firstname.lastname@example.org. Reach Smeltz at 412-380-5676 or email@example.com. Reach Wereschagin at 412-320-7900 or firstname.lastname@example.org. Reach Kilzer at 412-380-5628 or email@example.com.
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