This is a cautionary tale.
Kathleen Harriman, PhD, MPH, RN
Chief, Vaccine Preventable Diseases Epidemiology Section
Immunization Branch
California Department of Public Health
Hospital protocol failed in TB outbreak
http://news.yahoo.com/report-hospital-protocol-failed-tb-outbreak-001020984.html
AP By JUAN CARLOS LLORCA October 1, 2014 8:31 PM
EL PASO, Texas (AP) — An El Paso hospital worker who exposed more than 850 infants to tuberculosis was allowed to return to work despite showing symptoms of the disease
and coughing up blood at a hospital health screening, a federal report shows.
The report from the Centers for Medicare and Medicaid Services reveals that the nurse assistant on July 2 told
others at Providence Memorial Hospital she was fatigued and coughing up blood. She continued to work six more weeks later after a private doctor diagnosed her with TB.
The report, released late Tuesday, shows the hospital knew the worker had what is known as latent TB, which
means the bacteria's in the body but the person is not ill and can't transmit it. The symptoms should have triggered more tests to confirm if the disease had become active and contagious, according to the hospital's TB surveillance protocol. However, the guidelines
for the annual health screening that all employees undergo did not mandate further testing and no action was taken.
The worker was placed on leave after her doctor made the positive TB diagnosis in late August.
Of about 200 babies tested so far, only five have come back positive for latent TB and none with the active
form of the disease. Four of the five had been previously vaccinated, which could lead to false positives. Experts say that constant and prolonged contact with someone infected with TB is often necessary for transmission.
Treatment is being offered to all exposed children 6 months old or younger.
The hospital's federal funding remains in jeopardy until it shows it can meet "all of our basic health requirements,"
said David Wright, deputy regional administrator for the Centers for Medicare and Medicaid Services. The corrective plan calls for a revision of policies and retraining of employees, among other measures.
CMS investigators will go to the hospital before Oct. 11 to verify changes have been made to remove the immediate
jeopardy to patients' health. Within the next 60 to 80 days, investigators will return to confirm measures are still in place and that the hospital is compliant with all other requirements. If goals are met, funding will continue, Wright said in an email.
Even if the hospital avoids a cut in federal funding, the state may penalize it. Carrie Williams, spokeswoman
for the Texas Department of State Health Services, said a penalty is being considered and that state investigators will be back at the hospital at least two more times to verify the issues have been fixed.
Sierra Providence Health Network CEO Eric Evans said in a press conference last week that the hospital "should
have done more" when the employee's symptoms were revealed during her annual screening.
In a statement Wednesday, the hospital said it has implemented actions to improve its infection control program
and to address deficiencies identified by state and federal health authorities.