U.S. lawmakers held a hearing a few weeks ago to figure out why VA officials still weren’t following proper procedures for cleaning endoscopes that put more than 11,000 veteran patients at risk. Early this year, a VA investigation of three hospitals in Georgia, Florida and Tennessee found that veteran patients were possibly exposed to HIV, hepatitis and other infections through using non-sterile equipment in colonoscopies or endoscopies dating back to 2003.
In May, the VA inspector general expanded the search and conducted surprise inspections at 42 agency hospitals and found that fewer than half had adequate sterilization procedures. While the VA hospital system has gotten attention lately for lax cleaning standards, numerous other hospitals across the country may be risking patients’ lives due to improper cleaning of medical instruments.
In 2006, several infants died from a bacterial infection they contracted in a private Los Angeles hospital neonatal intensive care unit, probably due to “inconsistent and improper cleaning practices” in place for almost a year.
Infection Control Today described an example of a heart endoscope that was not inspected for cleanliness, which infected nine out of 19 heart surgery patients with E. coli within a two-week period within four days after their surgery.
These unfortunate cases over time point out the problem of inadequate hospital oversight.
In general, hospitals are inspected every three years for cleanliness and other safety procedures except when a problem is identified and followed up on. Most hospitals are checked every 18-39 months by the Joint Commission, the national organization that accredits hospitals, but they rarely measure treatment outcomes like hospital acquired infections. Additionally, according to one report, the Joint Commission does not keep data on how often hospitals are cited for violating disinfection standards, which fails to identify patterns of gaps in infection control. And, of course, the public doesn’t see any of this information.
We need to get dirty scopes out of our health care system.