VA takes heat at hearing on dental safety lapse

By Phillip O’Conner in the St. Louis Post-Dispatch

St. Louis — Congressmen and veterans took turns lambasting the Veterans Administration Tuesday for its handling of medical-safety failures at John A. Cochran Medical Center that may have exposed 1,812 veterans to infectious diseases.

The House Committee on Veterans Affairs held a special hearing at the U.S. Courthouse downtown to examine lapses in the dental clinic at the hospital in midtown St. Louis. Failure to properly clean instruments in the dental clinic put the veterans at risk of contracting hepatitis B, hepatitis C and HIV.

“I feel the very people who are supposed to have my back have put me in harm’s way, and I don’t know why,” said Terri Odom, a veteran of the Army and Navy, becoming teary-eyed as she spoke.

The VA sent letters in late June to those who had dental procedures at the center from Feb. 1, 2009, through March 11, advising them of the need to be tested. The warning touched off an outcry from some veterans, prompted congressional criticism and led to the chief of the dental clinic’s being placed on leave.

VA officials say the risk of exposure is extremely low.

But U.S. Rep. Russ Carnahan, D-St. Louis, said, “After service to our country, this is a battle our veterans should not face. I’m here to demand answers and action.”

Committee chairman Bob Filner, D-Calif., summed up the sentiment when he called the failures “unacceptable” and a “tragic situation.”

“On behalf of all of us, we want to make sure you know how bad everybody feels about this,” Filner said.

The breakdown at Cochran happened during the prewash of dental instruments, according to the VA. A detergent should be used to wash an instrument, such as a dental pick, before it goes into a heat sterilizer. Instruments were rinsed, but no cleanser was used.

The instruments were sterilized, which is thought to kill all microorganisms, including the viruses in question. The lapse was discovered in March in a routine inspection by an infection-control team. A top VA official testified that the agency needed time to review the information, identify patients and study the scope of the problem before it could notify veterans.

Committee members as well as several members of the area congressional delegation who participated in the hearing criticized that response. Filner noted that in the months-long interim veterans could have donated tainted blood or exposed family members to infection through sexual contact.

“You should have immediately made a public statement,” Filner said. “You’re dealing with potentially fatal diseases.”

Several congressmen also criticized the notification letter the VA sent to patients, describing it as “cold” and “callous.” They also criticized an emergency telephone line the VA set up, saying that many of those who answered were rude, had little information to offer patients and played down the seriousness of the errors.

Odom and another veteran, Susan Maddux, testified that parts of Cochran were filthy, with holes in walls and mold growing in the showers of some patient rooms. Odom said she even offered to clean the shower herself during a five-day hospital stay. Odom also reported seeing dirty and rusty medical equipment.

Maddux said that when she complained to the hospital’s patient advocate about the problems, she came away feeling she as if she were the one who had done something wrong.

The panel also heard from Earlene Johnson, 53, of south St. Louis, who said she warned management at John Cochran of unsanitary cleaning practices she saw in the sterilization process while she worked there. In November 2009, two months after raising her concerns, Johnson said, she was fired from John Cochran for “unprofessional conduct.” She is legally contesting the dismissal.

“If people were taking their job seriously, not passing the buck and pointing a finger, none of this would have happened,” Johnson said.

She told the committee that other Cochran employees were afraid to report problems, fearing retaliation. “Employees are intimidated,” she said. “They’re not going to speak to you. They need their job.”

Dr. Robert Petzel, undersecretary for health, acknowledged the failings at Cochran.

“Simply put, what happened at St. Louis was inexcusable and unacceptable,” Petzel said. “We took too long to investigate this and we took too long to notify, absolutely.”

Filner repeatedly interrupted Petzel’s prepared testimony, saying the VA official failed to grasp the seriousness of the situation.

“All I hear is the same justifications,” Filner said. “You’re not responding. You’re not clearly understanding the depth of the fear and the loss of trust.”

Filner called on Petzel and other top VA officials to call the affected veterans personally to discuss their cases and what the VA was doing to respond. Deviating from his written testimony, Petzel said the VA was ‘shocked and appalled at this unacceptable incident.”

“I’m personally embarrassed how long it took to get the investigation done and make notification,” he said. “Clearly, we failed to meet the needs of these patients.”

Petzel said that the notification was improperly handled and that more qualified people needed to be answering the emergency telephone number. “We will change that process,” he said.

The VA also will improve the process for employees and patients to report problems, Petzel added.

As of Monday, 950 patients had been tested and 826 showed no signs of infection, a VA official said. The VA has notified 261 patients of results. VA officials also said an undisclosed number had tested positive, but further study was needed to determine whether it was a result of dental treatments. A VA official testified that signs of infection would appear within six months of exposure.

“At six months, if you are testing negative, you are done worrying,” said Dr. George Arana, acting clinical quality assurance liason.

But others at the hearing disputed that claim, citing patients who initially tested negative for hepatitis only to later find they were infected.

In addition to the congressional investigation, the VA appointed an internal board to conduct a complete review to determine the reasons for the failure to follow correct procedures. Filner disputed that such a board could be independent. He said the committee would return to St. Louis in six months to see what progress had been made.