When VA hospital administrators ignore government guidelines on how to treat a problem that caused multiple patient deaths AND then tried to correct the problem using an ineffective treatment AND then failed to notify patients and staff about the problem until months later, what happens? They get bonuses.
Welcome to the Pittsburgh Veteran’s Administration where a Legionella outbreak killed five of our nation’s veterans and no one knew why … until water fountains were sealed off and patients stopped getting baths and showers. Turns out that the VA administrators knew why. VA Administrators reportedly knew about Legionnaire’s Disease in the hospital’s water supply but didn’t disclose it.
This Inspector General report showed that the VA system did not document system monitoring for proper Legionella control for “substantial periods of time” and when the VA did learn about positive Legionella cultures in its water supply, the hospital flushed the outlets with regular hot water – which does nothing to eradicate Legioinella.
What happened to the administrators who knew about the disease outbreak and reportedly delayed disclosing it to the public? VA Regional Director Michael Moreland got a $63,000 performance bonus for his excellent work.
When reporters went to interview hospital officials, they were met by armed federal police who told the reporters to leave.
For example, I didn’t know that Legionella had not been identified until 1976 – when more than 200 people at a American Legion convention became sick and 34 of them died.
Legionella lives in the biofilm that lines water pipes and thrives at temperatures between 95-115 degrees. It is difficult to culture because it is easily overwhelmed by other bacteria on the culture medium and because it has specific nutrient requirements – including cysteine and iron.
Legionnaire’s Disease causes about 5% of all community-acquired pneumonias, but immunocompromised patients are most at risk for bad outcomes. Legionella outbreaks occur most commonly in the summer and the fall and are frequently misdiagnosed. Air conditioning systems, humidifiers, and spas are some sources of infection. The most common source of hospital infections is contaminated drinking water. In other words, don’t use hospital water fountains.
Steaming hot water flushes with copper and silver ions is the only approved way to eradicate Legionella, but flushing a system with hot water must be done with care to avoid scalding patients and to avoid diluting the hot water with cold water in the system. A World Health Organization publication on Legionella (.pdf file) shows that a temperature of 158 degrees kills Legionella almost instantly.
The Wikipedia entry on Legionella links to another article alleging that bacteria, including Legionella, are being genetically modified in order to be weaponized.