Legislators Call for Hearings On VA Infection Control Lapses, Hepatitis Cases

by U.S. Medicine

April 12, 2011

DAYTON, OH—In the latest VA infection control lapse to come under public scrutiny, Ohio-based legislators are pushing for both U.S. House and Senate investigations into practices at a Dayton VAMC dental clinic that may have resulted in nine cases of hepatitis.

In early February of this year, Dayton VAMC announced that, due to improper infection control procedures, it was asking 535 veterans who received care in the dental clinic between January 2002 and July 2010 to come in for free screenings for HIV and Hepatitis B and C. At the time, officials said that the risk was low and isolated to the patients of a single clinician who allegedly had failed to change latex gloves and sterilize tools between procedures.

VA employees voiced concerns about the lack of infection control in July 2010, and VA began investigations into the allegations. That resulted in shutting the clinic down between August and September, and reassigning four dental employees, including Dwight Pemberton, DDS, to duties outside of the clinic.

In February, the Dayton VAMC issued a report stating that several employees may have known for years about the improper hygiene. The report also raised questions about Pemberton’s age and practice. Pemberton, who is 81, voluntarily retired on Feb. 11.

In the meantime, patient screenings have turned up seven patients with HCV and two with Hepatitis B that did not screen for either disease prior to their dental clinic visit.

The incident puts additional focus on an issue to which Congressional overseers were already sensitive. Immediately following the VA’s announcement in early February, Sen. Sherrod Brown, D-OH, called on the Senate Veterans Affairs Committee to hold a hearing to investigate the incident and VA’s response.

After the release of the Dayton VAMC report and with information that some patients were screening positive, Brown redoubled his efforts, calling for a full investigation from both VA and Congress. “A thorough medical center-wide organizational review is clearly called for,” Brown said in a release. “Shielding those who put Ohio’s veterans at risk is unacceptable.”

While investigations to date have not revealed that Guy Richardson, the Dayton VAMC director at the time, had any direct knowledge of the failures in the dental clinic, or that he impeded the investigation, VA removed him from his post. Richardson was moved to the Cincinnati-based headquarters for VISN 10. In March, Bill Montague, who has served as director at six different VA medical centers, was named interim director at Dayton.

Response Called Outrage

That move by VA has not placated legislators. “While making leadership changes at the Dayton VA was a necessary step, this is a puzzle with more than one piece,” Brown said. “You can’t change the culture of an organization simply by removing its top layer.”

Rep. Mike Turner, R-OH, called the move an “outrage” and a “bait and switch.” He said, “When members of our community ask who is being held accountable, so far we know Richardson has received a bonus and a promotion while veterans are being tested for possible HIV and Hepatitis infections due to the VA’s negligence.”

During recent VA budget hearings, it was revealed that Richardson received a more than$11,000 bonus last year.

Turner said he and House VA Committee Chair Jeff Miller, R-FL had planned to meet with Richardson during a visit to Dayton on March 14 but received word late the day before the scheduled meeting that VA would not be making Richardson available to them. In a letter to VA Secretary Eric Shinseki, Turner called the move “highly evasive and obstructionist.”

As of mid-March, neither the House nor Senate had scheduled a formal hearing into the incident.

Only the Latest Infection Control Problems

The problems in Dayton are only the latest in a series of infection control breaches at VA facilities. Last summer, it was announced that as many as 1,800 veterans may have been exposed to HIV and the hepatitis B virus while receiving dental care at the John A. Cochran Medical Center in St. Louis. The problems were related to disinfection and sterilization of instruments, and, after the disclosure, the VA said that safeguards had been put into place to prevent a reoccurrence of the problem.

A more recent concern at John Cochran turned out to be unrelated to infection control issues. The VAMC shut down for several weeks in February after staff found spots on surgical equipment. The spots on surgical trays were found to be caused by “metallic etching from chemical reactions occurring at the atomic level,” according to a hospital fact sheet, not blood or human tissue.

Numerous other issues involving the cleanliness of equipment, including scopes used for colonoscopies, have arisen in recent years in VAMCs around the country.

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