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Three patients and possibly more died last year at Huntington Memorial Hospital in a “superbug” outbreak thought to have been caused by improperly sterilized medical scopes, the Los Angeles Times reported today.
Last August, Pasadena Now reported that the hospital would say only that three patients had been infected but declined to speak in detail for the record about the outbreak.
Although the deaths apparently relate to the use of the Olympus Corp. duodenoscope, which Federal regulators have said is difficult to clean properly and thus can result in the transmission of potentially deadly bacteria from one patient to the next, a number of Huntington Hospital nurses have approached Pasadena Now to report what they said are widespread sterilization problems at the hospital.
The nurses alleged late last year that the original investigation into the reported superbug outbreak at the hospital involving a small number of patients being treated by the specialized scope led to the alleged discovery of potentially larger problems with cleanliness throughout the facility, possibly carrying far-reaching implications for more patients.
Those nurses pointed to a reportedly unprecedented shutdown of surgeries at the hospital which occurred as health officials were inside the facility conducting the investigation.
On August 25, 2015, the nurses alleged, Federal health inspectors effectively stopped over 30 unstarted surgeries from proceeding at Huntington Hospital after the officials reportedly discovered numerous violations of proper sterilization procedures during a surprise audit.
Steve Ralph, President and CEO of Huntington Memorial, released a statement at tghe time confirming that federal auditors from the Centers for Medicare and Medicaid Services (CMS) had been in the hospital and that “elective surgeries were temporarily halted Monday evening and resumed Tuesday.”
Ralph gave no specific explanation for stopping the surgeries other than to say that “as with any audit, business as usual can be disrupted.”
CMS officials would not discuss Huntington Hospital, citing department policies.
The shutdown of all 17 operating rooms at once is said to be unprecedented at Huntington Hospital.
According to the three Huntington Hospital Surgical Services nurses (two current and one former), the federal inspectors found mistakes in the assembly techniques of surgical trays which rendered the contents “not sterile.”
“When they encountered the same situation in three trays, the auditors ordered that the entire inventory of trays had to be taken down and reprocessed,” alleged Tina Gold, a former Huntington Hospital OR nurse who said she was in almost-daily touch with her previous colleagues. “This massive undertaking led to the cancellation of 38 elective [surgery] cases.”
Two other registered nurses who worked inside the Hospital’s Surgical Services department in 2015 independently corroborated Gold’s allegations.
Both nurses met with a Pasadena Now reporter, separately, and presented then-current California Board of Nursing registration cards and Huntington Hospital identification cards as proof they worked in the hospital’s Surgical Services, also known as the OR. Each declined to be named in this story.
The hospital’s website says that more than 10,000 surgeries are performed at the Huntington Hospital every year.
“It’s huge,” said one of the OR nurses, who explained the allegedly improperly sterilized instruments are also used outside the OR and throughout the hospital – from the delivery room to the emergency room to patients’ bedsides.
It is possible, the nurses said, that “all the other departments requiring sterile instrumentation” may have been issued, and used, improperly sterilized instruments for some time prior to the CMS inspection last August.
Each of the three nurses who spoke with Pasadena Now claimed he or she had become accustomed to opening improperly sterilized surgical trays in the past, returning them to the hospital’s Central Supply unit (CS) and reporting them to supervisors.
Separately, each nurse described having repeatedly been issued closed surgical ratchets and clamps in sterilized surgical trays — a serious procedural error because when those instruments are closed, bacteria-laden surfaces cannot be accessed and sanitized by the sterilization process.
Each also described being issued instruments without sterilization indicator tags (strips which change color during sterilization to prove their aseptic integrity) or still bearing old labels and strips from previous surgeries.
In today’s report in the Los Angeles Times, hospital officials said that they believed patient privacy laws prevented them from telling the public that the unnamed patients had died. It is still not clear how many patients may have been infected during the outbreak at Huntington or if only three died, the Times said.
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