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Across nation, VA hospitals in trouble over Legionnaires' disease policies

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Friday, Aug. 2, 2013, 12:01 a.m.

It's not just Pittsburgh.

Department of Veterans Affairs hospitals across the country failed to follow policies designed to stop the spread of Legionnaires' disease, according to a VA Office of Inspector General's report released on Thursday.

More than one-third of VA hospitals and clinical care facilities did not conduct proper planning and risk assessment required by a 2008 national VA directive to control the Legionella bacteria. If inhaled in water mist, the bacteria can become a potentially deadly form of pneumonia known as Legionnaires' disease.

“The report shows a clear lack of understanding at VA facilities across the country about proper protocol when testing for Legionella,” Sen. Bob Casey Jr., D-Scranton, wrote in an email to the Tribune-Review.

Casey, along with Republican Rep. Tim Murphy of Upper St. Clair, requested the nationwide investigation after a Legionnaires' outbreak in the VA Pittsburgh Healthcare System sickened at least 21 veterans, at least five of whom died, according to the Centers for Disease Control and Prevention.

The full scope of the Pittsburgh outbreak remains murky. VA workers at the University Drive campus in Oakland found alarmingly high levels of Legionella bacteria in the water system as far back as 2007, a Trib investigation revealed, but the VA and the CDC did not review those records or the medical records of veterans hospitalized there before the February 2011 to November 2012 outbreak period.

At least one family believes their loved one was killed in the outbreak but went uncounted by the CDC. Casey has asked the CDC to review the matter.

The report released on Thursday is the third produced by the Inspector General in response to the outbreak. At least one more, a criminal probe, is under way.

Nine of the 16 VA facilities with a history of hospital-acquired Legionnaires' — meaning patients caught the disease at the facilities — failed to follow the clinical and environmental testing guidelines spelled out in the 2008 directive, according to the report.

Three Pittsburgh facilities — the H. John Heinz III hospital in O'Hara, University Drive hospital in Oakland and the Highland Drive hospital, which no longer takes patients — are among those that failed to follow the rules, the report found. A Trib investigation in March and an Inspector General's report in April documented in greater detail the mistakes by VA Pittsburgh leaders that helped lead to the outbreak.

“This report is troubling proof that the mismanagement and incompetence that led to the Pittsburgh Legionnaires' disease tragedy is present at numerous VA medical centers across the country. The report very clearly documents how VA facilities put patients at risk by ignoring internal VA policies as well as federal guidelines governing infectious disease management and reporting,” said Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee.

The report is based on surveys that 182 VA hospitals returned to the Inspector General documenting their Legionella prevention efforts in 2012. That year, as an outbreak gripped VA Pittsburgh hospitals, testing for the disease at the Heinz and University Drive hospitals far exceeded any other in the country.

Of the 15,169 urine tests conducted at all VA hospitals to determine the presence of Legionella bacteria, more than 1,200 were conducted in Pittsburgh. No other hospital conducted more than 900. VA Pittsburgh accounted for about one-third of the 3,091 respiratory cultures taken that year, the report found.

Pittsburgh had more Legionnaires' patients than anywhere else. Eighteen of the 112 patients identified by the Inspector General were in Pittsburgh, more than three times the next-highest number of cases — five — that were identified at the VA Medical Center in Washington.

Investigators identified only four of those 112 Legionnaires' patients who definitely caught the disease from VA hospitals, the report said. It did not identify which hospitals those patients visited, but the CDC investigation of Pittsburgh's outbreak identified four patients who definitely acquired the disease in VA Pittsburgh facilities in 2012. The CDC report identified nine others who probably acquired the disease there.

“The inspector general's findings only bolster the case for significant reform at (the VA Pittsburgh Healthcare System) and around the country, and the need to pass legislation to require the VA to report outbreaks of infectious diseases to appropriate public officials,” Casey said.

Casey and Murphy have introduced bills that would require VA hospitals to comply with the same reporting requirements that apply to most hospitals — requirements that would tighten oversight.

“VA leadership needs to prove to veterans, Congress, and the public that they are committed to providing the best possible care. This starts with adhering to their own clinical standards and infection-control protocols and supporting the Infectious Disease Reporting Act,” Murphy said.

“Under this legislation, VA hospitals would have to notify public health agencies of a potentially deadly disease outbreak. While no report or legislation can undo the deadly Legionnaire's outbreak, we must work aggressively to ensure this kind of tragedy never happens again.”

The national VA is revising its guidelines for Legionella prevention in response to the Pittsburgh outbreak. The Inspector General suggested that those revisions simplify guidelines and provide “guidance, education and monitoring” to make sure they're followed.

In addition, the IG recommended the VA expand the number of facilities that should take extra steps to combat Legionnaires'.

VA Undersecretary of Health Dr. Robert Petzel, in a statement attached to the report, concurred with the recommendations and said they would be implemented within a year.

Mike Wereschagin is a staff writer for Trib Total Media. He can be reached at 412-320-7900 or

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