This article first appeared in the St. Louis Beacon, March 7, 2011 - WASHINGTON - A report by the Department of Veterans Affairs inspector general confirmed that John Cochran VA Medical Center had problems with the pre-treatment and cleaning of dental instruments, adding that managers did not "assure that corrective actions were consistently implemented."
But the report, released Monday, said that hospital officials had acted correctly in notifying 1,812 dental patients last summer of possible risk of infectious disease, even though "the occurrence of a patient-to-patient transmission of a blood-bourne infectious disease ... was unlikely."
Responding to the report, U.S. Rep. Todd Akin, R-Town and Country, sent a letter to Veterans Department head Eric K. Shinseki complaining that "it appears that once the field hearing was finished and the headlines faded away, it became business as usual at John Cochran."
Rep. Russ Carnahan, D-St. Louis, said, "We need to make sure veterans in the St. Louis region receive the best health care available, and I'm eager to work with the VA to find solutions based on the results of these and other ongoing investigations."
Carnahan and Akin were among the lawmakers who have complained to the Veterans Department repeatedly about conditions are Cochran, including:
- Last summer's admission by the medical center that sterilization problems in its dental clinic had potentially exposed about 1,800 veterans to hepatitis and HIV.
- A report in earlier this year that Cochran had suspended surgeries after staff noticed evidence of contaminated surgical instrument trays.
- Complaints by nurses at the end of last year about broken equipment, staffing levels and the lack of access to some medical supplies.
In a separate report Monday related to those nurses' concerns at Cochran, the inspector general confirmed that blood pressure machines and "personal protective equipment" were not always available at the hospital's telemetry unit, but said that the issue was later resolved and that staff could have gotten the blood pressure devices if necessary.
In its report on the dental clinic, the inspector general said dental-equipment cleaning issues at Cochran "were a long-standing problem that went unrecognized and unaddressed by Veterans Integrated Service Network" and Cochran's managers.
The report said the Veterans Health Administration identified "the deficiencies and took actions to correct them; however, those actions did not always resolve the issues. Responsible managers did not verify the adequacy of [equipment] reprocessing practices, nor did they assure that corrective actions were consistently implemented in response to VHA guidance and the Infectious Disease Program Office report. As a result, standard operating procedures were not developed in a timely manner for the reprocessing of dental RME" [reusable medical equipment], and those operating procedures "did not always match manufacturers' instructions." Also, the report said Cochran's Dental Clinic staff "had not received training on RME pre-treatment or reprocessing."
Even though the report "concluded that the occurrence of a patient-to-patient transmission of a blood-borne infectious disease" at the dental clinic was unlikely, the inspector general found that "the Clinical Risk Board adhered to the [correct] process . . .when it recommended disclosure to 1,812 patients potentially affected by breaches in the cleaning and sterilization processes."
The inspector found that Cochran "promptly set up and staffed its dental review clinic, made appropriate efforts to contact identified patients, and provided adequate support and follow-up to patients."
In his letter, Akin, who chairs a House Armed Forces subcommittees, said the inspector's report "highlights again the history of neglect at John Cochran."