Tuesday, March 15, 2011

The Revolving Door Of Crucial VA Clinic Dental Outbreaks

The Revolving Door Of Crucial VA Clinic Dental Outbreaks
The past and current lack of "adherence to sterilization practices" or "inadequate practices" at VA dental centers continues to rise. This blog has put together a summary of the VA facilities involved. We begin with the 2009 to 2010 notification letters sent to 1,812 veterans who may have been exposed to hepatitis B, hepatitis C and HIV; when a breach in protocol instrument processing took place at the John Cochran Veterans Medical Center in St. Louis, MO. The Associated Press reported in March 2011 that most of the 1,812 veterans potentially exposed have been tested with no infections connected to the dental clinic.

A Lesson Ignored ?
Noted on The Department of Veterans Affairs' website, in 2010 during the Cochran exposure was this statement, "In the past 18 months, VA has implemented more stringent oversight for reusable medical equipment to ensure a safer environment for patient care". As of this July 2010 in a press release deemed; "Lessons learned from St. Louis VA Medical Center are applied VA-wide" came this VA statement; "Under the Obama Administration, in the past 18 months, VA has implemented more stringent oversight of the safety of all its medical facilities. It is this more rigorous standard that directly led VA to identify and address problems at the St. Louis Medical Center. Additional resources have been allocated and new procedures and stricter enforcements are in place to ensure the safety of all Veterans who seek care at VA facilities. VA mandates transparency and accountability in its handling of mistakes or failures to meet VA’s high standards. VA’s processes lead the nation in terms of transparency and accountability. “VA is committed to ensuring that all our health care facilities are safe,” said Shinseki “VA will continue to investigate the actions of individuals involved and the proper administrative and disciplinary measures will be taken.”
However, sadly enough, the Dayton VA medical center must have missed that memo. The VA system may need guidance with implementing a "working" standard infection control practice at all VA centers, void of any human errors or staff and physician negligence.

Dayton VA Medical Centers Recently the Dayton VA Medical Center "dental clinic" failed to use proper sanitary procedures. As a result 535 veterans were exposed to hepatitis B , hepatitis C and HIV. Veterans who visited the dental clinic between January 1, 1992 and July, 28 2010 may be at risk. According to the Veterans Administration nine patients who received dental care at the Dayton VA Medical Center have tested positive for Hepatitis B and Hepatitis C following preliminary testing.
In part the exposure stems from Dentist Dwight Pemberton who admitted to not washing his hands between patients. The 81 year old also failed to change his latex gloves between patients and dental procedures. VA officials have initiated actions against three employees, including dentist Dwight Pemberton, all of whom may have infected patients at the VA. However,VA officials said because of Pemberton's retirement on Feb. 11, he no longer faces administrative action by the clinic.
The media coverage on both VA medical Centers has been compiled below.

John Cochran Veterans Administration Medical Center (VAMC) in St. Louis, MO and the Dayton, Ohio VA Medical Center
From OSAP;

What is OSAP?
Founded in 1984 and formally incorporated as a non-profit organization in 1985, OSAP is a unique group of dental educators and consultants, researchers, clinicians, industry representatives, and other interested persons with a collective mission to be the world’s leading advocate for the safe and infection-free delivery of oral care.

IC Compliance Breakdowns Hit The Press


An apparent breach of standardized practice related to dental instrument reprocessing occurred at the John Cochran Veterans Administration Medical Center (VAMC) in St. Louis, MO. The facility mailed notification letters to 1,812 veterans treated at the dental clinic between February 2009 and March 2010 stating their internal quality inspections determined that some instrument processing steps for dental instruments were not in compliance with their standard policies, creating a low risk of exposure to hepatitis B virus, hepatitis C virus and HIV. In a video interview, Dr. Gina Michael, a spokesperson for the VAMC, said that dental instruments were sterilized but the VA standardized sequence of instrument processing was not followed.

A CBSnews.com article on July 1 reported the VA Under Secretary for Health Dr. Robert Petzel saying that the problem arose because workers prewashing dental equipment failed to use a detergent before the equipment was sterilized allowing for a "phenomenally remote" chance that sterilization might not have been effective. The VA issued a press release on July 1 indicating that the lessons learned from the St. Louis VAMC are applied VA-wide.

In a related story at the Dayton VA Medical Center, an employee raised concerns about infection control practices at the dental clinic while an internal VA panel was reviewing clinic operations in late July. The allegations involved improper use of protective gear such as gloves, as well as the inappropriate use of burs. The VA closed the clinic for three weeks to investigate.

CDC Guidelines and FAQ on Sterilization-Cleaning
OSAP Charts
Comparing cleaning methods
How to clean dental instruments
20 steps to proper instrument processing

Mar 10, 2011
The Associated PressPosted : Thursday Mar 10, 2011 19:28:56 EST

ST. LOUIS — Surgeries have resumed at the Veterans Affairs hospital in St. Louis more than a month after a shutdown over sterilization concerns.
The John Cochran VA Medical Center suspended surgeries Feb. 2 after surgical trays were found to be pitted with corrosion. Procedures resumed Thursday.
Hospital director Rima Nelson says investigators who examined the sterilization processing department determined it was OK to start surgeries again. Nelson says they couldn’t determine a single source for the corrosion.
The sterilization concern was the second in less than a year at the Cochran center. Faulty sterilization at the center’s dental clinic last year raised concerns that 1,812 veterans were potentially exposed to hepatitis and HIV. Most of those veterans have been tested and no such infections have been connected to the dental clinic.

Feb 10, 2011
Surgeries still on hold at St. Louis VABy Jim Salter - The Associated Press
Posted : Thursday Feb 10, 2011 16:37:39 EST

ST. LOUIS — No timetable has been set for resuming surgeries at the Cochrane VA Medical Center in St. Louis, U.S. Rep. Russ Carnahan said Thursday following a meeting with the secretary of Veterans Affairs.

The St. Louis Democrat, a member of the House Committee on Veterans’ Affairs, said he asked Veterans Affairs Secretary Eric Shinseki for a top-to-bottom review of the St. Louis hospital.

“In my years in public service, this is one of the issues that has made me madder than anything I’ve ever seen,” Carnahan said in a telephone conference call with reporters.

Surgeries at Cochrane have been on hold since Feb. 2 after potentially contaminated surgical equipment was discovered. Last year, faulty sterilization at the center’s dental clinic raised concerns that 1,812 veterans were potentially exposed to hepatitis and HIV.

Shinseki, in a statement, called the meeting “productive,” and called the sterilization problem at Cochrane an “isolated incident.”

“We must not lose sight of the fact that a VA employee had the integrity and courage to identify the problem during a routine exam and notified supervisors,” Shinseki said. “This was the responsible and right decision to assure that no veterans were put at risk.”

Sterilization problems have arisen at other VA medical facilities across the country.

Officials at the Dayton, Ohio, VA Medical Center announced Tuesday that more than 500 veterans will be offered HIV screenings to determine if they were infected by a dentist who for 18 years failed to consistently follow the infection control standard of changing latex gloves between patients. Officials said there was no indication any patients had been infected.

In 2009, the VA said 10,000 veterans treated at its hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga., were potentially exposed to HIV and hepatitis, also because of faulty sterilization of equipment used for colonoscopies and other procedures.

Carnahan said mediocrity “thrives” at the St. Louis hospital.

“That’s not good enough for our veterans,” Carnahan said. “It’s not what they deserve.”

A private sector watchdog group called The Joint Commission was inspecting the hospital Thursday.

The VA said surgeries scheduled for Cochrane have been moved to other St. Louis hospitals, with the VA paying the cost.

All but a few dozen of the veterans treated with improperly sterilized equipment in the St. Louis dental clinic have been tested or refused testing. Three veterans tested positive for hepatitis, but officials don’t know how they were infected and none of the cases have been tied to the sterilization problems. A fourth also tested positive for hepatitis, but the VA said that person’s infection occurred from another source.

John Cochran Veterans Administration Medical Center (VAMC) in St. Louis, MO
June 29, 2010
By: Mike Owens
St. Louis -- A failure in cleaning dental instruments properly at the John Cochran Veterans Administration Hospital on Grand may have but 1,812 dental clinic patients at risk. The patients started getting certified letters Tuesday, advising them they may have been exposed to viruses: hepatitis and HIV.
July 2, 2010
ST. LOUIS (AP) — The chief of dental services at the St. Louis VA Medical Center is defending his staff and says he welcomes a Veterans Affairs inquiry into a mistake that might have exposed nearly 2,000 veterans to viruses. The VA said yesterday it was placing the dental chief on administrative leave while it investigates the sterilization procedure mistake. The VA said the risk of exposure is very minimal.
Still, the agency on Monday sent letters to 1,812 veterans who had dental procedures at the St. Louis facility from Feb. 1, 2009, through March 11 of this year, when the problem was uncovered.The VA is offering free tests to screen for hepatitis B, hepatitis C and HIV. Nearly 200 people had signed up for, or already had, testing. No illnesses have been found.The VA didn’t name the dental chief, but Danny Turner came forward to the St. Louis Post-Dispatch.
Turner told the newspaper in today’s edition that he stands behind his staff and that he blames politics for distorting the situation. “I have a lot of information that proves we were doing things correctly,” Turner said.
The VA warning prompted an outcry from politicians from both Missouri and Illinois — the five VA centers in the St. Louis area serve veterans from both states. “Things are done to get votes, and that’s a shame,” Turner, 63, said.Turner denied a claim made by a former employee that she saw dental instruments with dried blood even after they had gone through the cleaning process. “Our dental instruments are never that way,” he said. “I don’t know what she was talking about.”VA Undersecretary for Health Robert Petzel said yesterday the problem arose because workers prewashing dental equipment failed to use a detergent before the equipment was sterilized. He said that allowed for a “phenomenally remote” chance that sterilization might not have been effective.

Dayton VA Medical Center
March 15, 2011
Employees’ fear may have put vets’ health at risk
By Ben Sutherly,
Staff Writer Updated 10:10 AM Tuesday,
March 15, 2011

DAYTON — A culture of fear may have kept workers and supervisors at the Dayton VA Medical Center’s dental clinic from disclosing the unsafe practices of one dentist over 18 years, a congressman said Monday.

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, said the clinic is compact and open, so employees’ activities can be easily viewed by their coworkers.
Miller is concerned there may be a widespread culture at the VA in which employees are afraid to speak up when they see issues that affect patients’ health and safety. Dental clinic employees and supervisors had known of the dentist’s infection control lapses for several years, but it wasn’t until July 2010 that two employees reported the problem to an outside VA panel, triggering an investigation.

“For very few people to have stepped forward is troubling to me,” said Miller, who toured the facility Monday with U.S. Rep. Mike Turner, R-Centerville.
Continue Reading........

March 11, 2011
New VA hospital director an award-winning administrator
By Tom Beyerlein
, Staff Writer Updated 11:00 PM Friday, March 11, 2011
DAYTON — Department of Veterans Affairs officials on Friday said they coaxed an award-winning hospital administer out of retirement to help the Dayton VA Medical Center recover from the scandal surrounding a dentist’s unsanitary practices that may have led to hepatitis infections of nine dental clinic patients.
William Montague, who headed six VA hospitals including the Louis Stokes VA Medical Center in Cleveland, becomes the Dayton VA’s acting director Monday, replacing Director Guy Richardson, who was reassigned to a job at regional headquarters in Cincinnati.

Contact this reporter at (937) 225-7457 or bsutherly@Dayton

March 2, 2011
9 Dayton Veterans Test Positive For Hepatitis
Updated: 4:44 pm EST March 2, 2011
DAYTON, Ohio --
The Veterans Administration said Wednesday that at least nine patients who received dental care at the Dayton VA Medical Center tested positive for Hepatitis B and Hepatitis C following preliminary testing.
The Dayton VA has contacted 527 of 535 veterans seen by a dentist who failed to use proper sanitary procedures at the dental clinic.
The dentist, Dwight M. Pemberton, is accused of failing to change his latex gloves and sterilize instruments between patients.
Officials said of 375 patients tested so far, there have been seven Hepatitis C cases, two Hepatitis B cases and no cases of HIV.

February 26, 2011
Dayton VAMC Dentist Under Investigation Named
February 26, 2011 by Robert L. Hanafin ·
In early February Veterans Today (VT) reported that the Dayton VA Medical Center in Ohio was notifying Veterans who may have been exposed to Hepatitis or HIV/AIDS. Veteran’s activist Darrell Hampton has been a thorn in the side of Dayton VAMC management long before this investigation began, and he has worked closely with investigative reporters ...

November 23 , 2010
Another U.S. Department of Veterans Affairs' (VA) dental clinic has come under scrutiny for possible infection control issues.
The Dayton VA Medical Center's dental clinic in Ohio was temporarily closed from August 19 to September 10 after employees raised concerns about infection control practices during an internal VA panel review of clinic operations in July, according to Todd Sledge, a spokesman for the VA Healthcare System of Ohio. It was reopened September 19 after the staff was updated regarding infection control requirements.
"With the volume of work that goes through the Dayton clinic, we wanted to make sure the concerns were thoroughly investigated to determine if there was any basis to them and if they were accurate," Sledge told DrBicuspid.com.

For more information visit the VA Watchdog.com
In late 2008 and early 2009, the VA was plagued by a rash of reports about contaminated endoscopic equipment, including devices used to perform the colonoscopy procedure.
In some cases, the VA felt there may have been a risk of infection, so they notified veterans who had specific procedures performed at some VA facilities to be tested for possible exposure to HIV, and hepatitis B and C.
Because of variations in equipment cleaning procedures and variations in VA's self-reporting guidelines on how the equipment was cleaned, questions were raised about a possible nationwide problem with contaminated equipment.
On this page, we are posting all of the articles about VA's contaminated equipment. We will add more information is at becomes available... and, we will go back and research any earlier incidents of contamination and post that information as well.

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Wife of Vietnam veteran. Over 25 years of veterans outreach focusing on Post Traumatic Stress Disorder. Author For the Love of Jack, DAV Chapter 16 Auxiliary Chaplain, PTSD Consultant, Staff Writer Veterans Today. Editor and Publisher of Wounded Times. Also see website at http://www.namguardianangel.com/ . Student at Valencia Community College, Digital Media and Post Production.

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