Page 11 - May-June 2012

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May/June 2012
11
Public Citizen News
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By Barbara Holzer
Hundreds of patients who un-
derwent surgery last year at the
Sheridan Memorial Hospital in
Sheridan, Wyo., were potentially
exposed to infectious viral and
bacterial agents because the hos-
pital had stopped properly ster-
ilizing reusable equipment be-
tween patients.
However, the hospital did not
notify the patients of their pos-
sible exposure after the failure to
properly sterilize the equipment
was discovered.
The patients ultimately found
out — thanks to a whistle-blower
and media outreach by Public
Citizen.
In early March, a whistle-blow-
er provided Public Citizen with
an internal hospital memo dis-
cussing the lack of proper ster-
ilization for reusable laryngeal
mask airways (LMAs), which are
inserted in patients’ throats and
are used to provide anesthesia
and mechanical ventilation dur-
ing surgery. Last November, the
Wyoming Department of Health
had cited the hospital for failure
to properly sterilize the airways.
On March 13, Public Citizen
voiced its concerns about the
potential exposure in a strongly
worded letter to the Wyoming
Department of Health, urging
the department to require the
hospital to notify the affected pa-
tients and offer them screening
and, if necessary, treatment for
infections. On March 20, Public
Citizen sent a letter to the senior
leadership of the hospital urging
them to immediately undertake
such actions.
Public Citizen sent the letters
to reporters too. Shortly there-
after, the Wyoming Department
of Health, after consulting with
Centers for Disease Control and
Prevention (CDC), advised the
hospital to inform its patients
about the potential exposure
and screen them for hepatitis B,
hepatitis C and HIV infection. On
April 5, Public Citizen learned
that Sheridan Memorial Hospital
had notified several hundred sur-
gical patients who possibly were
exposed to infection during the
six-month period last year that
it deviated from proper steriliza-
tion procedures. The hospital
offered patients free testing for
the three viral infections noted
in the Department of Health’s
recommendation.
“We are pleased that Sheridan
Wyoming Hospital Informs Surgical Patients About Infection Risk
WIN!
Memorial Hospital acted respon-
sibly by notifying all surgical
patients who were exposed last
year to inadequately sterilized
airway masks and offering them
free screening for various viral in-
fections that could have resulted
from such exposures,” said Dr.
Michael Carome, deputy direc-
tor of Public Citizen’s Health Re-
search Group. “However, these
steps should have been taken im-
mediately after the hospital was
cited by the Wyoming Depart-
ment of Health in November 2011
for failure to properly sterilize the
airways.” Carome co-signed the
March 13 and 20 letters with Dr.
Sidney Wolfe, Health Research
Group director.
In May, Public Citizen received
a letter from Dr. Wendy Braund,
state health officer and senior
administrator in the Wyoming
Department of Health’s Public
Health Division, thanking the
organization for its concern for
Wyoming residents’ health.
“Thanks again for your vigi-
lance in protecting the health
of America,” Braund said in her
letter.
Change in procedure
LMAs come in contact withmu-
cous membranes, and the CDC re-
quires a high level of disinfection
for the devices. Also, the manu-
facturer of the LMAs explicitly
indicates that steam autoclaving
— a process using steam under
high pressure — is the only rec-
ommended method of steriliza-
tion for the devices. Sheridan
Memorial Hospital deviated from
this standard practice for six
months, only manually washing
the LMAs with a brush and using
an automated spray washer with
a low-level disinfectant.
“The hospital’s decision to
abandon steam sterilization was
reckless and potentially danger-
ous for patients undergoing sur-
gery at the hospital,” Carome
said.
During a November 2011 in-
spection, the Wyoming Depart-
ment of Health had discovered
the hospital was no longer prop-
erly sterilizing its LMAs. Appar-
ently, the agency required the
hospital to immediately resume
the recommended procedure
but did not take the crucial next
steps: requiring that the hospital
inform the hundreds of patients
involved so that they could be
screened for possible infections.
Some hospital staff allegedly
were aware of the threat of infec-
tion from the change in sanita-
tion procedures but were reluc-
tant to come forward for fear of
retaliation. If true, such an envi-
ronment represents a clear and
present danger at the hospital,
Carome said. The state Depart-
ment of Health should require
the hospital to implement poli-
cies and procedures that encour-
age staff to bring concerns about
potential patient safety prob-
lems to the attention of hospi-
tal management without fear of
retaliation.
“If it weren’t for the efforts of a
courageous whistle-blower who
brought this to the attention of
the public with the help of Public
Citizen, the hundreds of patients
who were recklessly exposed to
the inadequately sterilized air-
ways would still be in the dark,”
Carome said.