Summary of the Crisis

In January 11th it was announced to the media by the Southern Nevada Health District that there were 40, 000 patients exposed to infectious disease i.e. Hepatitis B &C and HIV by endoscopy clinics in Las Vegas that were using unsafe medical practices since March of 2004.

Letters were sent out to the clients that had procedures during that time that they may have been exposed to these diseases and to consult their doctor. What investigators found was that syringes and multiple use vials were being re-used on other patients during anesthetic procedures. Within a week all five clinics were closed pending further investigation. Since then several state legislative hearings have been held to hear testimony of investigating officials and patients of which we participated. We have held Town Hall meetings to answer question and dispel fears that the general public may have regarding possible infections. Electronic digital billboards, 7 in Las Vegas and 6 in Reno are presenting information about where to access answers to their questions. Patients are being advised that only one needle, one syringe and only one vial, is only for "me." This message is being instilled into the minds of consumers throughout the state. The nurses and technicians that administered the procedures unsafely have surrendered voluntarily their license to practice into the Health Department Board of Licensing. If it can happen in Nevada in the United of America, can it happen elsewhere in the modern world? Have our quality of medicine stooped to below what we find in third world counties?

Public concerns

What is the fate of the consumers of healthcare? How safe are they? How are they going to ensure that they are in no danger from the people they trust? Their concerns are that the patients do not understand the conditions and illnesses that they may have been exposed to. How do they now cope with potential future financial obligations to deal with new exposures? Who will pay for it? Some people think that they are now going to die and are beside themselves in panic.

Medical Concerns

People are afraid to have any medical or dental procedures performed regardless of assurances given to have a provider they can trust. Trust is a key issue that the patients have difficulty getting past when such an outbreak is looming.

Professional Training concerns

Are the nurses and technical staff getting the proper and adequate training in blood borne pathogens and universal blood precautions? Are the manufacturers labeling the devices being used that come in contact with patient's fluids properly in these situations common sense should prevail and that staff should refuse to follow any policies or instructions that clearly violate what has been taught.

Whistle Blower Protection

All staff must be aware of their legal rights and understand the whistleblower rights in their state. If they are insufficient to allow a nurse to report without consequences inadequacies in healthcare of healthcare delivery then they should advocate for better protection and go to their boards or legislators for better rules. There is strength in numbers and no patient should endure unsafe practices for fear of reprisals to staff members who report. In Las Vegas, clinic staff told inspectors they had been ordered by management to reuse the vials and syringes.

Bureaucratic Enforcement of Quality Performance Standards

The licensing and investigation section of our sate health departments are often under funded and overwhelmed by staff that are not fully qualified in all aspects of what they are supposed to be monitoring. Furthermore the workload at times requires much traveling and often they are unable to meet their own requirements regarding the frequency of their inspections. This allows possible violations to creep in during these intervals by new employees at the facilities being surveyed. We have also heard claims that qualified personnel to man the state licensing offices are difficult to find and hire. I have personally seen no evidence of that.

One issue that must be resolved is that the health workers in any state have the ability to renew their licenses in a timely manner and that there is full transparency about the performance of the offices, clinics, facilities and hospitals they work in. Not only the professionals in the community but also the consumers must have confidence in the process so that there is a renewed faith and trust in the system of oversight. We would like to see an increase in the requirements for re-certification on issues of occupational hazards and infection control in order to increase hygienic standards overall.

Center for Disease Control and Prevention Response to Health Emergencies--taxpayer concerns

In recent years the CDC budget has been reduced and its ability to respond to this kind of situation has been impaired. This time the CDC was informed quickly after Nevada investigators were able to connect the dots and reported the findings. They sent a team within days to assist the Nevada State Department of Health to complete investigations and inspections of all institutions in the state that performed these procedures and the job was completed in several weeks. Had this outbreak occurred in several states simultaneously or been larger it would have strained the resources of the CDC. We support greater appropriations by congress to the CDC to ensure the safety of healthcare in our country. Over 30 outbreaks of this kind have occurred in the United States in recent years involving infectious diseases but this situation is the largest in US history. We know that this is the tip of the iceberg. So that is why we are compelled to encourage an increase in financial support now and in the future for the CDC to be able to handle dire health situations when they emerge.

Legal and Justice Issues

At the time of the initial announcement the first reaction was panic, fear and anger. Many law firms in the region immediately began broadcasting their services over the radio and television and in the print media, hoping to pick up clients. It was ambulance chasing at its worst. Within 72 hours, civil lawsuits, class action and wrongful death suits were filed and within weeks the public was clamoring for criminal prosecution of the owners of the clinics and people involved in the negligent actions. The press also fueled the fire by giving out distorted information about the diseases that people were potentially exposed to. There were even those that called for the governor's resignation.

Community Response

On the positive side, the state held public hearings to get the stories from patients themselves and to hear first hand the anguish they experienced. This helped very much because it let people know that the government cared and would do something to help and to set policy and legislation in motion to insure that this type of situation would not be repeated. Education seminars for the public and midlevel health providers were planned and provided by the Nevada Hepatitis C Task Force that gave an opportunity for specialists to communicate and answer questions about blood borne infections. This is an ongoing measure and will continue as a regular program. Blood testing programs were established and sponsored by the major health plans to cover the needs of the patients notified by mail and others concerned about transmission of infections. Information about these resources was made readily available and accessible to the general public.

Lessons Learned

That in a profession where we are committed to do no harm, we must be diligent to errors and bad habits that we get into and see others do that may at first glance seem harmless. We should examine and understand the directions and policies that we follow on a routine basis and assess any potential possibility of negligence that may have a risk of the spreading of disease and act accordingly in response to it. This is how we can best provide a standard of care, continuity of care and quality that we can be proud of. Furthermore do not be afraid to alert those coworkers around you when you have a concern or discuss it with your supervisor. You may be saving a life. And in the same token that person is someone's loved one and could be you.

ANA\C The Nursing Voice--June, July, August 2008 Reprint with permission

Darla Burrow, MBA, Executive Director Nevada Hepatitis C Task Force and Bill Remak, B.Sc.M.T.; B.Public Health, SGNA, Chairman, National Association of Hepatitis Task Forces and California Hepatitis CTask Force