State Health Department Cites Two New York Presbyterian Hospitals for Violations in Legionnaires' Disease Investigation
ALBANY, NY, August 26, 2005 - The New York State Health Department today announced that it has cited the New York Presbyterian Health Care System for violations related to the investigation of a Legionnaires' disease outbreak that occurred earlier this year at its Milstein Pavilion, Columbia Division.
The Legionnaires' disease outbreak, which occurred from March to May at Columbia Presbyterian Hospital, sickened seven patients. Two of those patients subsequently died while in the hospital's care.
The Department's investigation found that Columbia Presbyterian Hospital failed to effectively notify patients and visitors of water restrictions and follow policies and protocols to help detect, monitor and eradicate Legionella bacteria in the water system. The New York Presbyterian Hospital, Weill Cornell Division was also cited for similar violations related to the monitoring of its water system for the Legionella bacteria.
State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H. said, "To protect patients in their care, we are requiring the New York Presbyterian Health Care System to correct the violations that have been identified. We also expect the Columbia and Cornell Divisions to fully implement the State's new hospital guidelines to combat the potential presence of Legionella bacteria in their water systems and thus prevent further outbreaks. A failure to correct the violations to the Department's satisfaction will result in enforcement action and fines."
Specifically, New York Columbia Presbyterian Hospital was cited for its failure to follow its own infection control policies and procedures for inspecting, approving and monitoring the use of an assistive breathing device by a patient in their care. Department inspectors determined that the hospital failed to inform the patient and family of hospital policy that only sterile water be used in all respiratory equipment utilized for assistive breathing.
Inspectors concluded that better communication between hospital staff and the patient's family may have prevented the use of contaminated facility tap water with Legionella bacteria, in the respiratory device. The hospital also failed to post signs in common areas of the hospital alerting the public of water restrictions imposed due to the Legionnaires' disease outbreak.
The investigative findings announced today follow the Department's decision in July to issue enhanced guidelines to assist hospitals in the education and training of all staff to better identify, monitor and eradicate Legionella bacteria in their water systems.
The new guidelines recommend that hospitals perform disinfection of water systems for Legionella bacteria twice annually throughout the facility and test quarterly in specific units designated for bone marrow or organ transplantation. Hospitals that detect Legionella bacteria in the water system should take immediate steps to disinfect water supplies and, with the Department's approval, may increase the water temperature for a short duration to help eradicate the bacteria, if necessary.
Dr. Novello said, "The guidelines are necessary precautions that we expect all hospitals in the State of New York to fully implement to protect patients in their care."
For more information on the State's Legionella guidelines please visit the Department's web site at: www.health.ny.gov.