California health inspectors dispatched to two Los Angeles hospitals following "superbug" outbreaks involving a hard-to-clean medical scope found numerous safety violations that appeared to put more patients at risk, according to a newspaper report.
The state declared an "immediate jeopardy" — meaning lives were at imminent risk — on March 4, 2015 at UCLA Ronald Reagan Medical Center, the Los Angeles Times reported Sunday. Inspectors found staff using contaminated water and a tainted liquid cleaner dispenser being used to ready colonoscopes and other devices for the next patients.
The rare "immediate jeopardy" ruling was used again three weeks later at Cedars-Sinai Medical Center. There inspectors found a "widespread pattern of potential ineffective sterilization and storage of surgical instruments" as well as problems with the disinfection of scopes.
Both hospitals quickly fixed the problems, according to the Department of Public Health. The "immediate jeopardy" was lifted after just three hours at UCLA and a day at Cedars. On follow-up visits, the state found the problems had not continued.
UCLA and Cedars officials said Friday they were not aware of any patients who were sickened by the sterilization problems the state regulators found during the March 2015 inspections.
Yet patient advocates said that the reports showed how infection control practices can lag even at top hospitals that had recently responded to bacteria outbreaks.
"You would think these very sophisticated leading facilities would have been on a hospital-wide alert," said Lisa McGiffert, who leads the safe patient project at Consumers Union, told the Times. "Hospital leadership is not putting enough resources into infection control."
At the time of the superbug outbreaks, which both began in late 2014 and extended into early 2015, officials at the hospitals said they had stepped up cleaning of duodenoscopes — the device made by Olympus linked to the infections.
Contamination of the scopes, lightweight tubes threaded through the mouth into the top of the small intestine, has been linked to bacterial outbreaks that sickened dozens of patients in hospitals around the country. In an outbreak at UCLA Ronald Reagan Medical Center, officials confirmed that patients had died.
Olympus recalled one of its duodeonscope models in January. An outside expert had told the company in 2012 that the design of the device could allow bacteria to remain trapped after cleaning.