Tuesday, January 30, 2007

Hospital story carries over the weekend

The Daily News finally got their opportunity to present the Prince Rupert Regional Hospital infection story, a report that first received its debut on Thursday night with the CBC and then was featured by the Vancouver papers and the Globe and Mail by the time the weekend had come to an end.

With the Friday paper probably on the printing presses before the noon hour on Friday, the paper was left out of the information presentation loop until Mondays paper finally hit the streets.

So what do you do when the story is all but out there and you’re not even at the party yet?

Well it’s all in the details we suppose once it’s no longer of the breaking news variety. And so the Daily News took the angle of looking at the different stages of the situation.

The Daily examined the background of the story with the interesting detail, that perhaps Northern Health didn’t receive, or interpret the cleaning instructions correctly from the manufacturer. That point, as well as an examination of the regular procedure for sterilization of utensils, the bureaucratic path to investigate it, as well as the delay in the timing of the announcement, all can be found from the front page story from Monday’s edition.

NH says 74 patients at “very, very low” risk after equipment improperly cleaned
By James Vassallo
The Daily News
Monday, January 29, 2007
Pages one and three

An improper cleaning procedure used on a surgical instrument at Prince Rupert Regional hospital has prompted Northern Health to issue warnings to 71 patients who were operated on between March and August of last year.

Although the equipment was sterilized and the risk of disease transference is considered to be very low, letters were sent out to those who may be affected as a precautionary measure.

”When this equipment was ordered for Prince Rupert Hospital the manufacturer’s specifications around the disassembly and cleaning of the equipment between cases somehow didn’t get transmitted correctly,” said Dr. David Butcher, NH’s vice president of medicine.

The equipment is known as an endoclench grasper, essentially a pair of scissor handles with a long shaft and an alligator clamp. Surgeons manipulate the clamp by the scissor handles to hold tissue in place while operating.

“They were following the same procedures they follow for all equipment… it’s taken apart, washed, dried and ten sterilized by being placed in an autoclave which is a high-pressure, high-temperature instrument that will remove any bacteria or viral particles,” he said. “But in this instance one part of the grasper was not completely dis-assembled down to its component parts. That additional missing step was noted by a staff member and the concern was raised that may have allowed contaminated material to go through the cycle of sterilization.”

The problem was identified back in August prompting the health authority to change the local cleaning procedure and initiate a review to determine if the incorrect practice was occurring across the region or just locally, as was the case. NH then initiated a policy review around how information around cleaning materials was relayed and changed some of their policies.”

“(Then) we looked at the use of this instrument to limit as specifically as possible to the number of patients whose surgery involved this piece of equipment said Butcher. “This particular piece of equipment was used by only one surgeon and used only in some of the procedures that he does,”

“We couldn’t go further and say specifically this equipment was used in every one of those cases, just that it had the potential to be used in these cases and we were able to narrow it down to those 74 patients who received notifications.”

Northern Health then initiated a full risk assessment alongside the B. C. Centre for Disease Control to determine the worst-case scenario in terms of the potential risk of harm to patients.

“The risk assessment said even if there was residual material left in the instrument, assuming the instrument each time went through the autoclave, it should have been rendered sterile,” he said. “They came back with a very, very low risk, but were not able to say the risk of transmission was absolutely zero. At that point we felt we had a responsibility to disclose to patients.”

That determination had been made in mid-December; however it was decided sending a letter to patients just prior to Christmas when a family physician may be less accessible would only heighten the potential anxiety of patients. Instead, the health authority waited until the new year, ensuring family doctors had all the relevant information and were available to help those who may be worried or want to undergo testing, he said.

“It took (five months) to go through all of that to make sure we weren’t notifying people unnecessarily,” said Butcher,” and at the same time so when we did notify people we had all the facts available.”

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