VA Leaves One Choice In Wake of Contaminated Equipment Scare - Get Screened
Jim Strickland: "If you've had any procedure suffixed with 'scope' or 'oscopy,' you should get in line and have your blood drawn."
03.30.09


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Editor's Note From Larry Scott: All information about the VA's contaminated equipment problems, including a look at the history of this situation, is on this page which is being regularly updated... http://www.vawatchdog.org/contaminatedequipment.htm
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I've followed the updates concerning the ongoing "Scope Cleaning" debacle that our Veterans Health Administration (VHA) has created for itself with great interest.

If you're a constant reader you know that I spent over three decades working in various capacities in a civilian health care setting. I started my career as a 91D20 (Surgical Technologist) in the Army and continued more or less in that field right up until retirement.

There isn't much I haven't done in a hospital. I've mopped the floors, emptied the bedpans, worked alongside some brilliant surgeons in heart surgery suites, I was a director of major heart surgery centers and I've made executive decisions in the board room. I've also had gastroenterology and other endoscopy services reporting up the chain of command to me.

My Army training was good and I capitalized on it.

I've also cleaned more catheters, instruments, devices and scopes that I care to remember. To train as a surgical tech in the Army in the 1960's meant that you were first proficient in the Central Supply and Sterilization arena.

We didn't have the word "disposable" in our vocabulary. We cleaned and reused rubber gloves, any and all kinds of tubing, and our entire array of surgical instruments were treated with TLC. Our boss, Major Lajoice C. Ricks, R.N., wouldn't have allowed anything less.

Over the years, modern medicine has learned more about how diseases are transmitted. One area of focus is the cleaning of instruments that are reusable from patient to patient. We are faced with diseases today that we understand are harder to eliminate by cleaning so we often use instruments that are completely disposable. Those are usually marked for "One Time Patient Use Only".

Of course manufacturers like that...they sell more that way. A debate rages over the economics of it all and that debate may never end. If the hospital is forced to purchase a new device for every patient when it's reasonable to clean, sterilize and use the device again, who pays for that? Insurance? Who pays for insurance? You can easily see where this leads us.

Some medical devices are obviously far too expensive to use once and discard. "Endoscopes", whether used for colonoscopy, bronchoscopy, sigmoidoscopy, duodenoscopy, laryngoscopy or laparoscopy are in that category.

The scopes found in hospitals today can range from $1,000.00 for a used device to well over $20,000.00 for a new piece of equipment.
http://www.proscopesystems.com/equipment.cfm

There are many other scopes used to prod, probe and poke at various parts of your insides. All scopes have a lot in common...they're a blessing for our health, they're expensive to purchase, they're delicate and they're very challenging to clean and maintain. The costs of repairs to damaged scopes in a busy hospital may run to the hundreds of thousands of dollars every year. http://tinyurl.com/d33tdh

Your doctor has his or her favorite scope in the array the hospital has available to use. If it's dirty or broken, the physician is forced to use another device and if it happens often, that doctor may not be a happy camper.

Those devices that are at the heart of the recent VHA controversy are colonoscopes. These are used to enable the gastroenterologist to peer deep inside your large intestine to visualize, diagnose and treat conditions of that part of your gut.

Colonoscopes, like all the others, become "contaminated" with blood, tissue and other bodily fluids during the normal patterns of use. In this particular use, these scopes are also usually in contact with feces and the mucus that coats the walls of your large intestine.

There may be various sorts of infectious agents within these contaminants that range from simple bacterial infections all the way hepatitis and the HIV virus.

Issues of cleaning arise with scopes because of their complexity and the fragile nature of the devices. There are various ports and channels that physicians pass instruments through as well as other openings with stopcocks and control valves to allow liquids to be flushed in and out of the targeted part of the body. Many of these tiny areas can't be seen during the cleaning process and attention to the details of cleaning protocols becomes critically important. Optics and lenses may be extremely delicate.

One of the more well known and important papers written about the cleaning of gastrointestinal endoscopes was published in 2003.  http://tinyurl.com/cu5jjp

In this paper numerous professional societies agreed on many of the important steps required to assure patient safety during these exams and treatments. Among the recommendations were such things as strictly following the manufacturers guidelines for each individual device and adequate training of all personnel to protect both the patients and operators.

It is also strongly recommended that a record be kept of each procedure that occurs, the name and procedure number (or other identifiers) of the patient, the time and date, the instruments used, the endoscopist performing the procedure and the type of scope and its serial number as well as any information about how the device was cleaned. This information is required to assist epidemiologists should an outbreak of disease occur.

Now you know a bit more about scopes and procedures than you did earlier. You understand that there are many types of scopes that are used over and over again due to the cost of the instruments.

You also know that these devices are extremely hard to clean and that each manufacturer will have their own strict recommendations of how their products should be cleaned and readied for use from patient to patient.

You've learned that each hospital department that uses scopes or other reusable equipment must keep detailed records of how the equipment is used, maintained and cleaned and that personnel who work with these devices must be highly trained and skilled so that they and you are safe. Records of their training must be available to demonstrate their competence.

All the above may be thought of as a golden chain of responsibilities and actions required to be positive that you won't leave the hospital sicker than when you went in. Physicians are taught, "First, do no harm" in their early classes in medical school. That promise traditionally trickles down to the staff who work with the doctors to make you better.

If any one link in the chain breaks, you may have a problem. It's apparent that now not only is there a broken link at some VHA colonoscopy centers, there are likely many more infractions in other endoscopy procedure disciplines that simply haven't yet been uncovered.

When I read the statement Larry posted, "The alert also noted the unspecified hospital -- later identified as the Murfreesboro center -- was cleaning the equipment only at the end of the day rather than after each patient as required by the manufacturer" I became almost physically ill. I can't tell you just how horrible this is to anyone who is even remotely familiar with how a device must be treated between patient uses. Any health care professional who has a bare minimum of knowledge couldn't allow a device exposed to blood or bodily fluid in one patient be used on another without first assuring that it was cleaned properly. It's inconceivable that this could happen...but it has.

These departments where the procedures occur are strictly required to have written policies and procedures that describe in detail every step of every process that occurs there. These policies and procedures are contained in manuals and updated frequently by administrative staff so that employees know exactly what to do in any given situation.

The captain of that particular ship is always a medical director...a physician who is credentialed in that particular specialty. In this case it would be a gastroenterologist. The medical director would be required to have signed off on all policy and procedure manuals that related to the cleaning of colonoscopes. Do we now have a case of physician leaders who signed papers that had no meaning to them? Were there written policy and procedure manuals as would be required by Joint Commission? Are the physicians who were using the devices complicit and approving of the shoddy cleaning practices or were they lied to and assumed that the staff were performing their tasks by the book?

Earlier today I'd have said that no physician would knowingly use a device improperly prepared. I'd have also bet that no hospital would have allowed "rinsing" between patients and throwing the manufacturers guidelines out the window. The rules I thought applied apparently don't so I won't hazard a guess as to whether any physician knew that a dirty tool was in their hands and deep in their patient.

If the strict guidelines for the use and cleaning of endoscopic instruments weren't followed in the GI labs, it's a smart bet that others didn't bother either.

As of the writing of this column, it's becoming more apparent that the VHA is circling their wagons. When we read, "There's no way to scientifically, conclusively prove they contracted this [HIV or hepatitis] due to treatment at our facility," we can be assured that there won't be any aggressive moves by VACO to provide us with the information we need to make rational choices about how to protect our health.

That's the traditional reaction from the Department of Veterans Affairs and it's too bad. At the moment VHA leadership should be comforting veterans and providing them with an action plan, to go to the mattresses seems a giant error, drearily reminiscent of other mistakes that the DVA tried to sweep under a convenient rug.

The veteran is left with but a single choice.

I strongly agree with and support Larry Scott's admonitions that every veteran who has had colonoscopy at any VHA Medical center in recent years be tested.
http://www.vawatchdog.org/09/nf09/nfmar09/nf032809-1.htm

At the very least, a blood test for hepatitis and HIV should be granted to you with little fuss or bother. I'd insist on that for future years while I'm at it. Those diseases may lie dormant for a long time.

I'll take it a step beyond that though. My insider knowledge of how hospitals work drives my thinking and I understand that this issue of how reusable devices are treated will more likely than not impact all reusable devices, particularly endoscopes.

It's my recommendation that if you have had any sort of endoscopic procedure whether it be cystoscopy, colonoscopy, bronchoscopy...any procedure suffixed with "scope" or "oscopy", you should get in line and have your blood drawn.

This isn't a signal to panic. Overall these procedures are safe and the benefits of having such a procedure far outweigh the risks.

I've just had a one on one conversation with a gastroenterologist at a VA Medical Center and he has assured me that in his institution, this isn't on his list of concerns. He talked about the staff at his hospital and used words like "professional" a number of times as he described what he thought of how well his particular service was being run.

For all his comforting talk, like Larry Scott, I'm also setting up my appointment to have my testing done.

If you're scheduled for an endoscopy tomorrow, now that this issue is getting attention, you're probably in the safest time period ever. Talk with your doctor about your concerns, don't cancel any of your scheduled care because of this.

However...it's apparent that the VHA isn't going to react quickly nor positively with a plan to reassure you so it's up to you to fend for yourself. While we had hopes of another approach to this from the VHA, what we're hearing is strictly defensive and self serving.

Call and make an appointment to visit your PCP. Don't delay.

The life you save may be your own.
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