Investigation Reveals Failures of Pittsburgh VA Hospital in Legionnaires' Outbreak
Southwestern Pennsylvania officials are expressing outrage after learning the details of a Veterans Affairs investigation into the deadly Legionnaires' disease outbreak at the VA’s Pittsburgh facilities.
According to VA Office of Inspector General, the VA Pittsburgh Health System failed to follow its own rules during an outbreak of Legionnaires' disease that left five veterans dead from early 2011 to late 2012.
The report released by the office Tuesday wrote that the VAPHS did not regularly flush out its water systems, which presumably allowed the bacteria to spawn. The investigators said the VA hospitals in Oakland and O’Hara were also guilty of inadequate maintenance of the copper silver ion system, which is used by hospitals to disinfect water.
The report said the VAPHS also did not conduct tests on positive cases of hospital-acquired pneumonia, which is the primary manifestation of Legionnaire's disease.
U.S. Senator Bob Casey said the report's conclusions were disturbing to him, noting that VAPHS apparently failed to carry out "simple, basic" maintenance on its water system.
"This has huge ramifications for, first and foremost, the veterans, but also their families and taxpayers," said Casey. He said he wants VAPHS to take "accountability for the management" as they enact the recommendations of the Inspector General's report.
While noting that VAPHS has already started to make changes, Casey expressed disappointment in the health system's handling of the outbreak. He said VA Pittsburgh was difficult to reach and repeatedly tried to downplay the seriousness of the infections.
U.S. Representative Tim Murphy (R-PA) called the Legionella outbreak an "outrageous and unacceptable failure" of VAPHS.
"It is a disturbing list of failures and a breach of trust on the most basic level between our veterans and the leadership of the VA Pittsburgh Healthcare System,” wrote Murphy, calling for an investigation by the Attorney General's office "to determine whether there was anyone involved in falsifying records, negligence, or willfully thwarting this investigation."
For its part, the VA Pittsburgh Health System said in a statement that it is already starting to implement the report's recommendations.
“VAPHS has taken appropriate steps, and continues to take action based on the review of the Inspector General and others, to control Legionella and ensure the safety and protection of Veterans," wrote Terry Gerigk Wolf, director of VAPHS. "VA Pittsburgh welcomes this feedback and remains committed to creating the safest environment possible for healing Veterans while also ushering in a new era of Legionella control.”
Several other government agencies are investigating the deadly Legionnaires' disease outbreak in Pittsburgh VA hospitals, including the CDC and the House Committee on Veterans Affairs.
Senator Casey said he’s working on a bill that would require VA hospitals to report any detection of Legionella bacteria to several authorities. Those to be notified under the bill would include the Centers for Disease Control and Prevention, the VA administration in Washington, state and county health departments, any affected healthcare provider and all of the affected VA employees.
Casey said he may draft additional legislation after further review of the VA's internal report.