Friday, January 26, 2007

PRRH infection warning risk gains province wide and national media attention

The story of the warning letters in early January from Northern Health over possible infections risks has gained some provincial attention, with a comprehensive story on the issue in the Globe and Mail.

One of the newspapers British Columbia contributors, Mark Hume has provided some background on the story, wrapped around the ordeal of one of the recipients of one of those letters.

The article was the front page story of the British Columbia section of the Globe, (and available nationally on their website) explained the involved process that Northern Health took part in to get to the warning stage, disclosed some of the concerns that Health officials may have and raised the question of timing regarding the advisory.

The incidents which are of concern, took place from May until August of last year, but as the article explains advisory notices were not sent out until January 8th, providing anywhere from a four to seven month delay. It’s a situation which has many wondering why Northern Health took so long to provide their information. It’s a lengthy delay that has been rather unsettling for those that received their letters this month.

While the article featured the story of one local man, it no doubt resonates with 73 other local residents who had a most unexpected and no doubt unwanted correspondence arrive in their mail boxes in the second week of January.

Hospital warns 74 of infection risk
Equipment used in surgical probes was under scrutiny for bad sterilization
January 26, 2007
Globe and Mail

VANCOUVER -- Robert Nelson spent yesterday "wandering in circles," waiting for the results of a battery of blood tests.

"Getting tested was a pretty major thing," he said shortly after leaving Royal Columbian Hospital in New Westminster. "They took seven vials of blood out of me to test to see if I am now HIV-positive, have hepatitis C or B, and a number of other things.

"It was a bad day."
Mr. Nelson, 56, was one of 74 surgery patients who received letters on Jan. 8 advising them that equipment that might have been used on them at Prince Rupert Hospital was not properly sterilized.

Following an investigation by the B.C. Centre for Disease Control, Northern Health sent a warning letter to the patients saying there is "no appreciable increased risk" that they were infected -- but suggesting they see a doctor to decide if they want to get tested for blood-borne diseases, such as HIV.

The letter says that last August staff realized a piece of new surgical equipment, used in laparoscopic surgical procedures, was not being sterilized according to the manufacturer's cleaning instructions.

"We can not be sure that your procedure involved the use of the particular piece of equipment. However, this equipment was used in about one-third of laparoscopic surgical procedures such as the operation you underwent," the letter said.

Northern Health said the equipment was sterilized according to standard procedures, but a step was missed in the process, raising concerns.

"The B.C. Centre for Disease Control has been consulted and has confirmed that this sterilization process was sufficient to destroy any infectious agents (virus and bacteria) so that there is no appreciable increased risk of transmission of infection to you as a result of the cleaning problem," the letter said. "However, we believe that we have a responsibility to inform you that this situation occurred so that you have the opportunity to discuss it with your physician, should you wish to do so."

Mr. Nelson said he has been worried since he got the letter.

"I left Prince Rupert to come down here [to Greater Vancouver] on Monday. . . . I was sitting on the plane thinking, 'Do I have any infection?' "

Mr. Nelson, who came to Vancouver to be fitted for a heart pacemaker and have the blood tests, said he is concerned that if his tests are positive, it could complicate his treatment.

"I came down here to look after my heart. You are thinking about all these crazy things that might be in your body and you just don't know what it all means," he said.

"It's been very stressful."

Laproscopy is a technique in which a small camera is used to facilitate appendix, hernia, gallbladder and colon surgery.

"I had an operation for a hernia," Mr. Nelson said. "They scoped my stomach and bowel, so of course I'm concerned."

He said that when he read the letter he was stunned and annoyed, because the sterilization problem was discovered last August.

"My question is, why did it take so long to notify us?" he said. "This is January. Seven months later? Come on, you guys."

David Butcher, vice-president of medicine for Northern Health, said the delay was necessary because the situation had to be fully investigated before patients were notified.

"We needed to identify as closely as possible which patients may have been involved and so that chart audit process took a while. . . . Secondly, we needed to understand just what the risks were, so risk analysis [had to be done], and thirdly, there was consultation with the medical staff around the disclosure and around the notification."

Dr. Butcher said that although a review showed there was no appreciable extra risk of infection, the BCCDC could not absolutely rule out the possibility of infection, so it was decided to notify patients.

"They could not give us a report that said there was no risk of transmission. And so with that information we felt that the right thing to do was to disclose, knowing that it would cause some people anxiety, knowing it would cause a concern, but in the larger picture knowing also that it is very important that we are transparent and accountable.

"We have to balance the issue of upsetting patients with the need to disclose when there is any risk," he said.

Dr. Butcher said the equipment was being disassembled and sterilized according to standard hospital procedures, but a staff member noticed that one step in the disassembly process had been missed, raising the possibility that a small part could have remained contaminated.

He said Northern Health so far is not aware of any postoperative infections linked to the laparoscopic equipment.

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