Prescription for Justice
According to a report recently released by the Pasadena Public Health Department, nearly a dozen people may have died due to a superbug infection at Huntington Hospital contracted by improperly sterilized medical instruments.
All told, 16 people were infected with bacteria.
The news comes after the National Labor Relations Board ruled in favor of registered nurses seeking to form a union at the local hospital. There was already an election, which the nurses lost. But now they can hold another vote.
The report was also released after the hospital rehired two pro-union nurses who were dismissed for allegedly sharing a computer password.
According to the city Health Department, Huntington patients contracted the pseudomonas aeruginosa “superbug” through infected duodenoscopes, or flexible lighted tubes that are threaded through the mouth, throat and stomach into the top of the small intestine.
A pseudomonas infection is caused by pseudomonas aeruginosa, a type of bacteria which healthy people can carry with no side effects. However, in sick people or people with compromised immune systems it can lead to serious illness and sometimes deadly infection. The infections are difficult to treat because the bacteria can resist many types of antibiotics used to kill it.
Previously, the hospital only reported three deaths related to last year’s outbreak.
“PPHD hypothesizes that there was inadequate disinfection of the duodenoscopes, possibly due to a combination of factors, including the complex design of the scope that may impede effective reprocessing,” states the report.
According to the US Food and Drug Administration, more than 500,000 procedures using duodenoscopes are performed annually in the United States. The procedure is the least invasive way of draining fluids from pancreatic and biliary ducts blocked by cancerous tumors, gallstones or other conditions.
But the construction of the scope makes it easy to transfer dangerous bacteria to patients.
The device has a movable mechanism at the tip that changes the angle of the accessory, which allows it to access the ducts to treat problems with fluid drainage. If not properly cleaned, bacteria can remain in the movable part of the scope and infect a patient.
But instead of cleaning the product by hand, per FDA recommendations, officials at Huntington were using compressed air purchased at Home Depot, states the report.
“These are complicated medical devices and they are difficult to clean. Unquestionably there are other infections and other deaths related to these types of scopes,” said attorney Peter Kaufman, who has filed lawsuits against the hospital and the manufacturer on behalf of two patients.
“The incidents have not been well reported and the manufacturer has not done a good job communicating the risk to hospitals,” Kaufman said.
“We don’t know how negligent the hospital was, but if they failed to follow the manufacturer’s instructions on disinfection that is below the accepted standard of care,” he said. “Olympus has had more problems than any other manufacturer.”
Kaufman has filed two lawsuits against Huntington Hospital and Olympus Medical Systems for wrongful death, product liability, negligence and two counts of fraud. Kaufman represents the families of Thomas Lombardo and Azniv Tavidghian, who were patients at Huntington and died after being treated with the scopes.
In April, US Rep. Ted Lieu, D-Torrance, released FDA data showing that 350 patients at 41 medical facilities around the world were infected or exposed to tainted scopes between January 2010 and October 2015.
In March 2015 three people died and four more became ill in a superbug outbreak at UCLA Ronald Reagan Medical Center after being treated with Olympus scopes. Four children became ill after being treated with the same type of scopes at Cedars Sinai Medical Center.
Health Department officials had to ask hospital staff twice before they agreed to notify patients treated as far back as January 2013, according to the report.
Prior to that, the only patients notified had procedures performed with the scopes between January and August 2015.
“They have assured our Health Department they are notifying us about procedures with those scopes going back to January 2013,” said Pasadena Public Information Officer William Boyer.
According to hospital spokesperson Derek Clark, hospital officials have already notified patients who underwent procedures from January to August last year and are in the process of notifying patients who had earlier procedures.
There have been no new infections since August 2015, according to Dr. Paula Verrette, senior vice president and chief medical officer of Huntington Hospital.
“We will continue to be in close contact with the appropriate health authorities and patients who may have been affected by these scopes or their representatives,” Verrette said.
Huntington Hospital performs about 10,000 surgeries a year, according to the hospital’s website.
The city report also states that the hospital violated state regulations mandating that “any outbreaks of disease” be reported within 24 hours. The hospital did not inform city officials until Aug. 20, although the earliest infection occurred in January 2013.
The report recommends that Huntington Hospital follow Centers for Disease Control and Prevention guidelines for cleaning the scopes, implement a robust infection control unit to monitor future outbreaks, return old scopes as soon as possible, and follow all notification guidelines in the future.
This is not the first time the hospital has come under fire for its sterilization practices. After news of the deaths surfaced last year, nurses with the hospital said they were accustomed to opening improperly sterilized surgical trays, returning them to the hospital’s central supply (CS) unit and reporting them to supervisors.
Closed surgical ratchets and clamps in sterilized surgical trays were also issued to nurses. The closed clamps cannot be accessed and sanitized during the sterilization process. Equipment was also issued without sterilization tags, which change colors during sterilization to guarantee the integrity of the instruments.
Federal health inspectors shut down the hospital’s 17 operating rooms in August after discovering the sterilization problems and forced the rescheduling or transfer of 38 patients facing non-life-threatening surgeries.
The report was released days after the National Labor Relations Board sided with two nurses who allege Huntington Hospital fired them for their efforts to unionize.
Allysha Almada and Vicki Lin said they were fired after Almada shared a user name and password to a computer program with fellow nurse Vicki Lin without permission. Lin was also fired. Nurses are prohibited from writing down passwords and must memorize them. Nurses are required to have the passwords to about 20 different systems and frequently write down that information.
The NLRB ruled that the hospital must reach an agreement with the two women or take the case before an administrative law judge.
The ruling also throws out an original 539-445 vote against the union. A second vote can be held after a 60-day notice is provided, according to the settlement.
“HMH administration has been trying to sweep this terrible incident under the rug to protect its public image, rather than do what’s right by patients and their families,”Almada wrote in an email to the Weekly.
“Did they believe they were above the law? They failed to report the potential contraction of the superbug to patients until the Pasadena Public Health Department repeatedly asked them to do so. HMH was not following nationally recognized standards or manufacturer-recommended guidelines for cleaning the scopes, using compressed air canisters for drying,” she wrote.
“Administrators and managers may not understand that this is unacceptable, but nurses do. It’s time for HMH administration to understand what happens to patients when they don’t listen to the expertise and professional advice of nurses. They deserve more respect,” Almada wrote