Hospital on Long Island May Have Exposed 177 to Viruses
By PATRICK HEALY
Published: June 16, 2004
Source: New York Times
Nearly 180 patients of North Shore University Hospital in Manhasset were informed last week that they might have been exposed to H.I.V. or the hepatitis virus because instruments used for routine endoscopies might not have been properly disinfected.
Eighty-six of the patients have returned to the hospital, on Long Island, for precautionary blood tests, and none have tested positive for hepatitis or H.I.V., the virus that causes AIDS, a hospital spokesman said yesterday. The New York State Department of Health is investigating the lapse, a spokesman said, but has not taken action against the hospital.
Red flags went up at after hospital officials discovered that two employees had failed to test a disinfectant bath used to clean the endoscopes, said Terry Lynam, a spokesman for the North Shore-Long Island Jewish Health System, the operator of the hospital. One was suspended without pay and the other was fired, he said.
The fired employee had a pattern of failing to keep proper records, Mr. Lynam said, but was not previously disciplined. Mr. Lynam would not identify either employee, but said they worked in the department of perioperative services at North Shore's Manhasset campus and were responsible for cleaning the hospital's used endoscopes.
"It was an accountability issue," Mr. Lynam said of the firing. "The person, to be quite honest, just didn't get it."
Each year, the hospital performs more than 5,000 endoscopies - procedures in which long, rubbery tubes are snaked down a patient's throat or through the lower intestine to examine ulcers and polyps and to check for signs of cancer and other disease.
Although there are no national or state standards for cleaning the endoscopes, Mr. Lynam said the technicians scrubbed all the instruments by hand, machine-washed them with disinfectant and water and then air-dried them. It is the machine-washing stage that has come into question.
The employees failed to test the water supply to the washing machine, a process that ensures that the scopes are washed with disinfectant, rather than pure water, Mr. Lynam said. He said hospital officials discovered a 12-day stretch beginning April 28 where there was no record that the employees had checked the disinfectant levels.
The hospital sent out letters last Wednesday to the 177 people who underwent endoscopies during that 12-day period.
"For your safety, you should undergo blood testing even if you have felt entirely well since your procedure," the letters say. "We are recommending that you be tested now and again in six months for hepatitis B, hepatitis C and H.I.V."
Mr. Lynam said the nurse who oversaw the department that disinfected instruments would now check records every day to ensure that the employees - who were not required to have any medical training - were doing the proper tests.
Dr. David A. Peura, president-elect of the American Gastroenterological Association, said the chance that a patient had been infected with any errant virus or bacteria was a less than one in a million. Mr. Lynam said the letters and blood tests were a precaution. "The letter undoubtedly was unsettling," Mr. Lynam said. "But we're trying to ease those concerns by raising what is a minuscule likelihood that any of these infections could be transmitted. This is the first time it's ever happened at this hospital." But critics of the cleaning standards for endoscopies said the North Shore lapse was hardly an isolated case. The procedure's popularity has surged in recent years as improving technology allows doctors to perform more complex tests and operations without cutting open a patient, doctors in the field said. About 15 million endoscopies are performed annually.
As more endoscopies are performed, Jamie Sheller, a Pennsylvania lawyer who has sued an endoscopy clinic, said, hospitals across the country are putting more pressure on employees to clean the instruments so they can be used again.
"The scopes are expensive so a hospital only has a few, so they need to get them cleaned and get them back out there," Ms. Sheller said.
She said that washing machines were easily corroded by harsh disinfectants and employees received little training in how to properly clean the instruments.
"I hear about one a month where hospitals have to send letters out to a couple hundred people," Ms. Sheller said. "It's happened in California. It's happened in Michigan. It's constant."