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mctree

Some perspective is in order: The 2nd case of hepatitis was Dec 18. The patient was interviewed Dec 28 - 10 days later. It was another 13 days before the clinic was inspected. 23 days had elapsed since the reporting of the second case. I don't have enough detail in the story to know when the practice was stopped once the syringe reuse became known. The time appears to be a day and overall that appears to be fast compared to the other steps. I may not have some knowledge of the events that others have.

It may have not have been obvious syringes were reused early in the inspection, or how the inspectors came up with the information, by observation or by interview. Frequently the rooms are darkened. An inspector may have followed the path of the endoscope or cleaning procedures in the room without catching on to what was happening with the syringes. Was the information present only at the end of the day (from interview or collaboration with another CDC inspector)? Were the inspectors looking at the procedure from another room? When was the syringe reuse stopped? I have not seen the details.

I just comment the CDC inspection resulted in a practice ending in around one day compared to 23 days to make the inspection happen. I consider that the CDC did a good job. Part of the "big picture" is getting the right people to do the inspection; this took days. Consider the result if an inspection missed the cause, or found a deficiency that was not the cause, so that the real problem went unchecked and patients continued to get infected.

Obviously I would hope no one was infected on that day, but would not all of us wish that the inspection occurred one day earlier, one week earlier, or a month earlier? While it is likely no one got hepatitis on a single day; it is quite possible that over a month it happened.

I am a one who administers propofol. My comments:

Hepatitis C is carried by 1-2% of the population, so that might give some measure of risk to others. Any one room would likely have no patients with hepatitis C on any given day.

Hospitals are scrutinized to a much greater extent; they would not get away with doing something like this as a matter of policy. Of course, not having to follow strict procedures keeps outpatient center costs lower. Some of the rules imposed on hospitals do not contribute to safety, some do.

The nurse anesthetists are likely employees of the clinic or functioned like an employee as far as making the rules of how the work was done, that's inherently a compromising situation if you are told to do something by your boss. It's not clear who the boss was here, the doctor-owner or a clinic manager. This procedure is so bad I am a little surprised that the nurse anesthetists did not do things correctly once they saw inspectors present.

Propofol in a 50 cc vial is a vial size is a larger than needed vial size for this procedure ( depends on the procedure length, although they seem to be short based on the patient volume and the number of procedure rooms). Propofol supports bacteria growth very well and mixing vials might also place patients at risk for bacterial infections, including sepsis.

I can understand the observation team not interfering with the procedures and I would understand the big picture could include finding something else other than propofol contamination that might apply to other facilities, Another poster made an inference that the procedure was corrected on the 11th, and I would say this was fast action.

There is another story about the use of multiple dose vials. The risk of cross contamination would be zero for multiple dose vials if proper procedure of only entering a multiple dose vial with a never used syringe and needle ( never used means not used even on the current patient.) Propofol does not come in a multiple dose vial.