20 isle vets exposed to unsterilized dental tools

Twenty patients in the Veterans Affairs Pacific Islands Health Care system potentially were exposed to blood-borne pathogens in May from unsterilized dental instruments, the VA said Friday.

"Although the risk is determined to be extremely low, (VA) staff will contact those patients to disclose this incident," the VA said in a notification to congressional members.

"The Department of Veterans Affairs and VA Pacific Islands Health Care System care deeply about being forthright with those who trust us for their health care," the emailed message said.

For the patients who so desire, blood tests for hepatitis B, hepatitis C and HIV will be administered, with a scheduled follow-up at 13 weeks and six months, the VA said.

"VA sincerely apologizes to veterans who may have been affected," the agency said.

The lapse comes on the heels of news in May that the waiting times for VA doctor’s appointments in Hawaii are the worst in the nation. The nationwide scandal over waiting times for new patients led to the resignation of VA Secretary Eric Shinseki, a Kauai native and former Army chief of staff.

In May the VA reported that Hawaii veterans waited an average of 145 days for their first appointment with a primary care physician.

Facing congressional criticism, Wayne Pfeffer, director of the VA Pacific Islands Health Care System, said earlier this month that he hopes to reduce waiting times for new patients to 30 days within three months.

Neither the health care system nor Trip­ler Army Medical Center provided responses to Hono­lulu Star-Advertiser questions Friday about the dental error.

The VA Pacific Islands Health Care System patients may have been exposed to unsterilized dental equipment May 23 and 27, according to the congressional notice.

"Per standard procedure, the instruments had been sent to the Trip­ler Army Medical Center Central Materiel Service for sterilization processing, and when they were returned to the facility, dental department staff failed to notice wrapping indicated the instruments had been cleaned but not completely sterilized," the VA said.

"Review of the patient log indicated that the instruments potentially were used in minimally invasive, routine dental procedures on 20 patients before being discovered on May 27."

According to the American Dental Association, all dental instruments that contact the bloodstream or mucous membranes and are heat-stable (i.e., don’t melt) should be sterilized after each use by steam under pressure, dry heat or chemical vapor.

"Sterilization is a process that destroys all microorganisms including bacterial spores (which are most resistant). Disinfection (or cleaning) is a process that destroys most pathogenic organisms, but not all microbial forms (like spores)," the Chicago-based organization said in an emailed statement. "So it’s still possible for an instrument that is disinfected to transmit pathogenic organisms. There are also different levels of disinfection depending on the type disinfectant used and the length of time that the disinfectant is in contact with the instrument. High-level disinfection destroys all microorganisms, but not necessarily high numbers of bacterial spores. Intermediate-level disinfection destroys bacteria and most fungi and viruses, but not necessarily bacterial spores. Low-level disinfection destroys most bacteria, certain fungi, and viruses."

The Centers for Disease Control and Prevention, meanwhile, said on its website that once items are cleaned and dried, those requiring sterilization must be placed in containers or peel-open pouches that allow penetration of the sterilant and act as a barrier to subsequent microbial contact.

Since the incidents became known, the VA said it has taken the following actions:

» Identified veterans who were potentially affected.

» Notified appropriate offices within the VA and the Defense Department, including facility infection control officers.

» Conducted VA dental staff re-education on sterilization process identification.

» Held "collaborative" meetings with leadership at Tripler.

» A review of inventory was ordered and completed.

» Initiation of a joint VA Pacific Islands Health Care System and Trip­ler "root cause analysis" to determine how the lapse happened and how it can be prevented from occurring again.