Reports blame Pittsburgh VA outbreak on staff

Internal reviews cite series of mistakes

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Within about a month of the first public announcement that the Veterans Affairs Pittsburgh Healthcare System had experienced a Legionnaires' outbreak, the VA knew the disease had flourished because of VA employees' decisions, errors and lack of knowledge, and not a water disinfection system that local leaders tried for more than a year to blame for the deadly outbreak.

That was the conclusion reached by two internal VA reviews of the outbreak that were completed in December 2012 and only recently obtained by the Pittsburgh Post-Gazette.

It was on Nov. 16, 2012, that the Pittsburgh VA first publicly acknowledged that it was experiencing a Legionnaires' outbreak that eventually was known to have sickened 22 veterans, six of whom died shortly after contracting the deadly form of pneumonia.

Both December 2012 reviews were unflinching in casting blame on the people in both the Pittsburgh VA's management and the regular line workers who ran the copper-silver ionization water disinfection system that was designed to control the spread of legionella.

The reviews reached essentially the same conclusion even though they were conducted using very different methods.

“There were issues related to multiple ongoing engineering processes and operations. As a result, redundant Legionella prevention mechanisms were not in place,” concluded a review by a blue ribbon panel of VA experts who came to Pittsburgh in December, 2012, for a two-day inspection of the issues that led to the outbreak.

In particular, the report, authored by Gary Roselle, the director of the VA’s National Infectious Disease Service, noted: “In general, [the Pittsburgh VA] has been known for robust Legionella prevention activities; however vigilance for Legionella prevention may have waned in recent years.”

The Pittsburgh VA was for decades considered by many to be the site of the most advanced Legionnaires’ prevention methods and protocols, all of it based on the research of Victor Yu and Janet Stout, internationally known Legionnaires’ experts who was fired and forced to resign by the VA, respectively, in 2006.

Dr. Roselle’s report, completed on Dec. 22, 2012, validated a more cursory review done just weeks earlier using VA records and phone interviews by Oleh Kowalskyj of the VHA’s Capital Asset Management, Engineering and Support office.

In his report, dated Dec. 10, 2012, Mr. Kowalskyj noted a slew of errors in operations and knowledge -- many of which were also found by Dr. Roselle's later report -- that could have individually or collectively played a role in causing the outbreak:

* The Pittsburgh VA's hot water systems were consistently operating below the 120-degree minimum the VHA recommended, and the hot water tanks were "well below the 140/130F temperature minimums to inhibit bacterium."

* The amperage on the copper-silver ionization system, which should have been operating between 2 and 3 amps to be effective, repeatedly operated below 2 amps.

* The VA staff only made alterations to the copper-silver system after getting back monthly tests on the copper and silver ion levels in the water -- meaning the ion levels could be wildly out of range for weeks before they were adjusted.

* One VA staff member who worked with the ionization system told him that "until about a month ago" he did not know that the pH level in the water could affect how the copper-silver system performed.

* Test data showed that "for much of the past calendar year weekly copper testing, performed on-site, showed copper concentration levels were typically maintained at the lower range end with periods dropping below required minimums."

"Physical water treatment components are maintained in serviceable conditions," Mr. Kowalskyj concluded. "However, the investigation has revealed operational, process, record-keeping (missing monitors and discrepancies), oversight, and educational gaps which directly impact the monitoring and efficacy of the installed systems."

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans Affairs, said: "VA Pittsburgh Healthcare System officials knew they had a legionella problem on their hands for more than a year, but instead of immediately asking for proper outside help in addressing the situation, they opted for a 'learning as you go' approach in which they repeatedly failed to adhere to proven legionella control measures and even VA's own policies."

The Pittsburgh VA said in a statement Tuesday the VHA is still reviewing administrative actions that led to the outbreak, and that its "water safety regimen is now one of the most rigorous in the health care industry. We are dedicated to doing whatever it takes to minimize the risk of Legionella and create the safest environment possible for our nation's Veterans to heal."


Sean D. Hamill: shamill@post-gazette.com or 412-263-2579. First Published March 11, 2014 8:47 PM

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