Call for national action after Vegas look-back
Senate majority leader acting as 'clearinghouse'
An outbreak of hepatitis C virus (HCV) that recently sparked a massive testing effort affecting 40,000 patients in Las Vegas comes as the largest, latest "look-back" in a series of ambulatory care exposures that shows no signs of stopping. Unsafe needle safety practices, particularly during administration of anesthesia, are the common theme of the outbreaks.
"Highly specialized medical units — surgicenters, radiology units, endoscopy units — that are separate from hospitals and no longer under the umbrella of infection control — often don't have real knowledge about contemporary infection control practices," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville, TN. The series of outbreaks raises a compelling question that goes beyond guidelines and expressions of shock and outrage: "What is the responsibility of public health, organized medicine, and health care in supervising and educating these units?" he says. "This has gone beyond [the state level]. This is a problem."
The American Association of Nurse Anesthetists (AANA) called for some type of medical summit on the issue while reiterating its guidelines. "These types of incidents are completely unacceptable," says Wanda Wilson, CRNA, PhD, president of the 37,000-member AANA. "We invite other national health care organizations, as well as governmental entities and drug manufacturers, to work with us to restore public trust and achieve this goal of ensuring and enhancing patient safety when it comes to the use of needles, syringes, and single-use medication vials."
Schaffner agrees, noting that "we need to get the dialogue going." The conversation needs to involve the major infection control groups along with the professional associations representing the various disciplines that practice in ambulatory care and freestanding clinics, he says. "A combination of ignorance, negligence, and cost savings has conspired to having people cut corners when it comes to infection control," he says. Indeed, knowing all too well the history of prior incidents and the current nature of infection control in ambulatory care, CDC director Julie Gerberding, MD, MPH, warned in press reports that the Las Vegas outbreak could be the tip of the proverbial iceberg.
While previous outbreaks in ambulatory care failed to capture the public imagination — and engender sufficient outrage to spark change — the sheer scale of the Las Vegas look-back has jaws dropping and phones ringing. A hotline on the issue has received more than 25,000 calls, with some demanding state and national action to prevent future occurrences. Nevada lawmakers say the state will take a leadership role on ambulatory care infection control both locally and nationwide, according to published reports. Senate Majority Leader Harry Reid, (D-NV) said he will act as a "clearinghouse" on the issues, but it was too early to discuss specific national legislation.
Anesthesia practiced according to professional guidelines is safe, but the incidents must be used to address the problem once and for all, Wilson emphasizes. "What is clearly not the answer to the problem is for any group of providers — physician or other — to insist that 'it couldn't happen to us,' because that's certainly not in our patients' best interests," she says. Speaking of the patient, the Consumers Union, publishers of Consumer Reports — which has hounded hospitals to improve infection control in recent years — also is aware that health care is shifting to ambulatory care settings and taking patient infections with it. "We have focused on hospitals because we felt that is where the major problem was and where the most patients are infected," says Lisa McGiffert, director of the Stop Hospital Infections project at the Consumers Union. "But we agree that it has to go beyond that. Many of the states are including ambulatory surgical centers and outpatient clinics in their [infection control] legislation. We definitely will be looking at this in the future."
The number of incidents is occurring with striking regularity. Last year, a physician anesthesiologist in Long Island was investigated by the New York State Department of Health for allegedly reusing syringes to draw up medicine from multidose vials. The department contacted approximately 8,500 patients who had been treated by the physician prior to Jan. 15, 2005, urging them to be tested for hepatitis and HIV. However, in the latest HCV outbreak in Las Vegas, the providers administering the anesthetic were not physicians, the American Society of Anesthesiologists (ASA) emphasized. "The training and education anesthesiologists receive is what sets them apart from other medical "providers" who deliver anesthesia care," the ASA stated. "Typically, an anesthesiologist has completed four years of college, four years of medical school, and has completed a minimum of four additional years of training accredited by the Accreditation Council for Graduate Medical Education in the medical specialty of anesthesiology. Anesthesiologists are responsible for the safe delivery of over 90% of all anesthesia care provided in the U.S. They can and do, in some settings, supervise and direct nonphysicians such as nurse anesthetists and anesthesiology assistants."
The ASA encouraged patients to ask the following questions before undergoing any procedures requiring anesthesia:
- Who will administer my anesthesia medication? Do I have an option to request an anesthesiologist?
- What type of anesthesia care will I be given?
- Do you throw out needles, syringes, and vials after every patient use?
A painful past
In recent years, four large outbreaks of HBV and HCV infections have occurred in the United States among patients in ambulatory care facilities that include a private medical practice, a pain clinic, an endoscopy clinic, and a hematology/ oncology clinic. The 2002 pain clinic outbreak in Oklahoma resulted in 31 clinic-associated HBV infections and 71 HCV infections. In that outbreak, a nurse anesthetist reportedly drew medication into a single large syringe and injected it into the IV lines of numerous patients. In a previously reported endoscopy clinic outbreak, it appears that reinserting needles into contaminated multiple-dose anesthetic vials resulted in HCV infection to 19 patients. In the hematology/oncology clinic outbreak, syringe reuse apparently led to the contamination of saline bags used to flush out implanted catheters, resulting in 99 identified HCV infections. All four outbreaks could have been prevented by adherence to basic principles of aseptic technique for needle use and the preparation and administration of parenteral medications, CDC investigators stressed.1,2
Since willful intent to put patients in danger seems an unlikely explanation for all the incidents, it is clear that some portion of the problem is educational. A survey of anesthesiologists conducted by the AANA after the Oklahoma outbreak in 2002 found that 3% of anesthesiologists who responded indicated they reused needles and/or syringes on multiple patients. CRNAs, other physicians, nurses, and oral surgeons reported reuse at 1% or less, the AANA reported. Extrapolating from the survey's findings, 3% of anesthesiologists and 1% of CRNAs equated in 2002 to approximately 1,000 anesthesia professionals who might have been exposing more than a million patients to risks of contaminated needles and syringes, the AANA concluded. According to Wilson, the AANA distributed this information widely among public and professional communities, including to the CDC. Despite these alarming results, the AANA was unable to generate interest in a summit meeting of health care organizations to address the issue, she says. "Perhaps if the issue had been given more attention at the time, we wouldn't be revisiting it again today," Wilson says.
More evidence of a safety culture problem within the anesthesiology community came in 2006, when a survey revealed that anesthesia providers (APs) in hospitals with some of the best infection control programs in the country were reusing needles and contaminated multiple dose vials on multiple patients.3 The researchers surveyed anesthesiologists working at the seven national prevention "epicenter" hospitals that collaborate with the CDC on infection control projects. Anesthesia providers reported reusing syringes, entering IV tubing and multidose vials without using aseptic techniques, using equipment from more than one patient without cleaning or disinfecting the items, they found. The web-based survey netted 339 (32%) responses from 963 APs. Thirty-one percent said they have used a "used" syringe or a needle in a multidose vial.
The problem is not just anesthesiology, however. Even as the number of medical procedures performed in physician offices, clinics, and other ambulatory care settings continues to increase, these settings still operate with little regulatory oversight, experts warn. Nor is the only issue bloodborne pathogens, which are much easier to pick up in surveillance than bacterial infections. The hepatitis outbreaks resulted in calls for action and public health discussions that included the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC). HICPAC formed a working group to look into the issue, but ultimately no guidelines or recommendations resulted. One issue cited in early discussions was that the problem that led to the outbreaks was not so much a lack of guidance but a lack of compliance. Indeed — in terms of guidance — in 1999, a panel of infection control experts issued a consensus document calling in part for nonhospital health care settings to seek the advice and consultation of hospital-based ICPs or infection control consultants.4 The general perception is that cost disincentives and other factors have left that recommendation largely unfulfilled.
References
- Williams IT, Perz JF, Beel BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004; 38:1,592-1,598.
- Centers for Disease Control and Prevention. Transmission of hepatitis B and C viruses in outpatient settings — New York, Oklahoma, and Nebraska, 2000-2002. MMWR 2003; 52:901-906.
- Herwaldt LA, Schultz-Stubner S, Kuntz J, et al. Infection control practices among anesthesia providers (AP) in the 7 CDC prevention epicenter hospitals. Abstract 315. Society for Healthcare Epidemiology of America. Chicago; March 18-21, 2006.
- Friedman C, Barnett M, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: A consensus panel report. Infect Control Hosp Epidemiol 1999; 20:695-705.
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