Colonoscopies may have exposed 293 Hospital patients to HIV
Baystate Noble Hospital has notified colonoscopy patients that the scopes used in their procedures may not have been properly disinfected.
Springfield-based Baystate Health said Friday that because of a lapse in disinfection procedures, 293 patients who had colonoscopies at Noble between June 2012 and April 2013 are at risk of having been exposed to blood-borne pathogens during their procedure.
Baystate Health acquired the much smaller and formerly independent Noble Hospital in July 2015.
Baystate Health spokesman Benjamin Craft said everyone affected, the 293 patients, have been sent a letter notifying them. Baystate also established a hotline, (413) 794-8955, which it is aiming to keep available for those affected to get more information.
A news release from Baystate issued Friday quoted Dr. Sarah Haessler, an infectious-disease physician and Baystate’s head epidemiologist, saying the risk of infection from the colonoscopies is quite low.
“Due to the function of the water irrigation channel and the phase of disinfection at which the failure occurred, the risk to patients is very low. However, that risk is not zero, so we’re taking the necessary steps to address these issues and provide patients with the resources they need.”
As Baystate explained the situation Friday, Noble Hospital began using new colonoscopy equipment in June 2012. The new colonoscopies required a different approach to disinfection than instruments used previously at Noble.
Due to a failure in training, the disinfection of those endoscopes between procedures did not adequately expose the devices’ single water irrigation channel to high-level disinfection during the last phase of cleaning, Baystate said in a news release.
Noble received new equipment and training that enabled it to appropriately disinfect the endoscopes involved in April 2013 and Noble officials considered the matter closed, Baystate said Friday.
But the Massachusetts Department of Public Health brought the issue to light during a site visit in December 2015.
Sterilization issues involving endoscopes used to look inside the body for various procedures have cropped up across health care in recent years.
Nationally, the Centers for Disease Control and Prevention says that 50 million Americans undergo colonoscopies each year. The CDC also says more outbreaks have been linked to contaminated endoscopes than to any other medical devices.
In 2015, failure to disinfect endoscopes possibly exposed 281 patients in Hartfordto drug-resistant bacteria and was also implicated in the deaths of two patients in California.
The duodenoscope is different than the endoscopes used for routine upper gastrointestinal endoscopy or colonoscopy, according to the FDA.
In 2013, an Atlanta outpatient surgery center sent letters to 456 colonoscopy clients warning them they may have been exposed to HIV as well as hepatitis B and C.
That same year, study at five hospitals nationwide finds that three out of 20 endoscopes retained bits of “biological dirt” from past patients, putting people at risk for hepatitis and infection, as reported in the AARP Health Talk website.
This national concern led Baystate Health last year to convene a multidisciplinary team to assess the safety of endoscopes and disinfection processes throughout the organization. This team continues its work, Baystate said.
Ronald Bryant, president of Baystate Noble, said:
“On behalf of Baystate Noble Hospital and Baystate Health, I apologize to all those affected by this failure in safety. The safety of our patients is our very highest priority, and we take full responsibility for our part in allowing these patients to have potentially received unsafe care.”
Bryant stayed on after the Baystate takeover. His tenure as head of the hospital goes back to 2011.
Dr. Stanley Strzempko, interim chief medical officer of Baystate Noble Hospital, said:
