Department of Veterans Affairs
Office of Inspector General
Office of Healthcare Inspections
Report No. 13-00994-180
Healthcare Inspection
Legionnaires’ Disease at the VA
Pittsburgh Healthcare System
Pittsburgh, Pennsylvania
April 23, 2013
Washington, DC 20420
To Report Suspected Wrongdoing
in VA Programs and Operations:
Telephone: 1-800-488-8244
E-Mail:
vaoighotline@va.gov
Web site:
www.va.gov/oig
Legionnaires’ Disease at the VA Pittsbur
gh Healthcare System, Pittsburgh, PA
Executive Summary
The VA Office of Inspector General (OIG) Offi
ce of Healthcare Inspections conducted a
review of Legionnaires’ disease (LD) at t
he VA Pittsburgh Healthcare System (VAPHS)
at the request of the VA Secr
etary, Senator Robert P. Ca
sey, Jr., Congressmen Michael
F.
Doyle and Tim Murphy, and the Chai
rmen and Ranking Mem
bers of the House
Committee on Veterans’ Affairs
and the Senate Committee on Ve
terans’ Affairs. They
asked that OIG evaluate whether VAPHS wa
s adequately maintaining its system for
preventing LD. Additional ques
tions regarding mitigation of
risk at other VA hospitals
will be addressed in a subsequent report.
VAPHS has a long history of comprehensive
mitigation efforts for LD. Following the
recent outbreak, VAPHS instituted numerous additional measur
es. However, we found
that while employing copper-silver ionizati
on systems during 2011-12, VAPHS allowed
ion levels inadequate for
Legionella
control to persist. There was a lack of
documentation of system monitoring for subst
antial periods of time and inconsistent
communication and coordination between the
Infection Prevention Team and Facility
Management Service staff.
We also found that VAPHS di
d not conduct routine flushi
ng of hot water faucets and
showers, especially in ar
eas that are infrequently us
ed, as recommended by the
copper-silver ionization system manufactu
rer. We found that VAPHS conducted
environmental surveillance in accordance wit
h Veterans Health Administration (VHA)
Directive 2008-010. However,
VAPHS responded to positive cult
ures by flushing distal
outlets with hot water at normal operati
ng temperatures, a corrective action not
consistent with VHA or Centers for Diseas
e Control and Prevention guidance. In
addition, VAPHS did not test all health
care-associated pneumonia patients for
Legionella
as specified by VHA guidance for tr
ansplant centers with a history of
healthcare-associated LD.
We recommended that the VAPHS Director ensur
e that any disinfectant system in use
for
Legionella
prevention is monitored and ma
intained in accordance with
manufacturer’s instructions, that hot-wat
er faucets and showerheads are routinely
flushed, and that close c
oordination between the Infe
ction Prevention Team and
Facilities Management Service staff occurs
. Additionally we
recommended that the
VAPHS Director ensure that wh
en environmental cultures ar
e positive, actions taken
comply with VHA guidelines, an
d that all healthcare-associ
ated pneumonia patients are
tested for
Legionella
infection.
