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Report: California Hospitals Fumbled Response to Scope-Related “Super Bug” Infections

Inspectors declare “immediate jeopardy”

After Los Angeles was hit by “super bug” outbreaks last year involving hard-to-clean medical scopes, state health inspectors descended on two of the city’s largest hospitals and found numerous safety violations that appeared to put more patients at risk, according to an article in the Los Angeles Times.

At UCLA Ronald Reagan Medical Center, the state declared “immediate jeopardy”––meaning that lives were at imminent risk––on March 4, 2015, after finding that the staff was using contaminated water and a tainted liquid-cleaner dispenser to prepare colonoscopes and other devices for the next patients. Hospitals can be fined up to $100,000 for “immediate jeopardy” violations.

The ruling was used again three weeks later at Cedars-Sinai Medical Center, where inspectors found a “widespread pattern of potential ineffective sterilization and storage of surgical instruments” as well as problems with the disinfection of scopes.

Both hospitals quickly fixed the inspectors’ concerns.

At the time of the “super bug” outbreaks, which began in late 2014 and extended into early 2015, leaders at the two Los Angeles hospitals said they had stepped up the cleaning of duodenoscopes––the devices linked to the infections. At least six people died at two Los Angeles area hospitals, including UCLA, from those infections.

But the inspectors from the state Department of Public Health reviewed more than the cleaning of duodenoscopes. They looked at the hospitals’ practices in disinfecting all types of gastrointestinal scopes, as well as surgical equipment.

Some problems appeared to be longstanding. For example, at Cedars, inspectors found that employees were not following safety standards as they packed trays of surgical instruments for sterilization in a machine. They found instruments ready to be delivered to the operating room tightly packed in a tray, with employees not opening devices such as forceps and clamps at their hinges so that sterilizing fluid could get to all surfaces.

At UCLA, the inspectors said that the hospital had no one supervising the nurses and technicians who cleaned equipment in the rooms where gastroenterologists treated patients with scopes. The hospital also did not ensure that those employees were competent in disinfection practices, the report said. For example, the inspectors found nurses using a cleaning product without being aware that the liquid had to remain on a surface for three minutes to work.

Both hospitals linked their outbreaks to duodenoscopes sold by Olympus Corp. The company recalled one of its duodeonscope models in January 2016. An outside expert had told the company in 2012 that the design of the device could allow bacteria to remain trapped after cleaning.

Source: Los Angeles Times; May 15, 2016.

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