At the request of Congressman Tim Murphy (PA-18) the subcommittee on Oversight and Investigations for the Veterans' Affairs Committee convened a congressional hearing Tuesday regarding the recent outbreak of Legionnaires' Disease at the VA Pittsburgh Health System (VAPHS). Following the hearing, Rep. Murphy released the following statement.
"Today's hearing revealed five major breakdowns that raise new questions as to whether the Legionnaires' Disease outbreak at the Pittsburgh VA Hospital, which has received national awards for infectious disease control programs, could have been prevented.
"First, the Centers for Disease Control, the VA Healthcare System, and other hospitals do not operate from uniform standards to control Legionella in the water systems. Although the CDC testified there should be zero tolerance, clearly, the VA didn't follow that standard. The VA set its own standard - 30% of distal sites having the presence of Legionella - and that's not acceptable and poses too high of a risk to patients. This testimony and scientific reports from the CDC into the outbreak confirms my belief that there be needs to be a new unified standard for VA and hospitals to follow to eliminate the risk of Legionnaires' Disease.
"Second, as part of its review of the outbreak, the CDC did not fully evaluate whether this issue is a regional problem or compare the Pittsburgh VA Hospital against other large facilities nearby, including UPMC Presbyterian Hospital, the Western Psychiatric Institute and Clinic, and the Petersen Events Center.
"Third, manufacturers of the copper-silver system employed by the VA to kill Legionella bacteria in the water supply made stunning accusations that the VA improperly maintained and monitored its system with untrained staff members. The manufacturer was asked by the VA to make recommendations for keeping the hospital water supply safe, but critical data regarding the water's bacteria copper-silver ion levels was withheld from the consultant. And perhaps most upsettingly, the manufacturer's employees claim the VA falsified test results to obscure problems with the water supply during a site visit. Yet these serious accusations were not reported up the chain to VA leadership, and we don't yet know why.
"Finally, the Pittsburgh VA Hospital has been held up as the gold standard for infectious disease control, receiving national accolades and recognition for its internal commitment to quality and patient care. During the hearing, we learned key information about these cases was withheld from physicians and hospital employees. This breakdown in information-sharing occurred at several levels and poses a serious concern.
"This investigation will continue because our veterans, the hospital staff, and community deserve to know whether VA officials did everything possible to prevent the Legionella outbreak and what steps we can take to prevent this from ever happening at the VA, or any other hospital, again."