Hepatitis outbreak spurs moves to toughen regulation

By Marshall Allen

Sunday, March 1, 2009 | 2 a.m.

The history of health care in Las Vegas can be divided into two eras: the one before last year’s hepatitis C outbreak and the one after it.

Before the outbreak, patients and government officials seemed resigned to the region’s poor level of health care. After it, the status quo was no longer good enough.

That defining moment occurred Feb. 27, 2008, when public health officials announced an emerging crisis: Nurses at a colonoscopy center had triggered a hepatitis C outbreak by reusing syringes and single-use medicine vials. Because of the staff’s wholesale disregard of clinical hygiene, more than 40,000 people needed to be tested for infectious diseases. It’s likely that more than 100 people contracted the disease at the clinic, according to the Southern Nevada Health District.

Greed seems the root cause of the outbreak. The clinic’s owner, Dr. Dipak Desai, ran a high-volume colonoscopy business that cut corners for profit. He’s now under criminal investigation for possible billing fraud and negligence in connection with the outbreak.

Just as disturbing: Insiders at the clinic apparently knew about the dangerous practices, but did not blow the whistle.

Outrage over the crisis resounded throughout the state. From elected officials to medical providers to co-workers and neighbors, it seemed that if someone wasn’t directly affected by the reckless practices, he knew someone who was.

“I think it was a shock to the system,” said Larry Matheis, executive director of the Nevada State Medical Association. “For some, there was a period of denial that this could happen. There was a disbelief at what seemed to be going on.”

The reaction didn’t stop at rage and denial. The anger fermented into a rallying cry. The episode has become a watershed moment in the state’s medical history. Health officials, doctors and legislators have turned crisis into opportunity. Reforms have been implemented and more are expected.

“There has been a lot of looking at our systems and seeing what we can do to make sure this doesn’t happen again,” Matheis said.

Nevada legislators are mulling at least eight bills that address aspects of the crisis.

“In my years at the Legislature, by far this is the most significant and comprehensive health care reform I’ve ever seen,” said Assemblywoman Sheila Leslie, D-Reno.

The pending legislation would:

• Require outpatient surgery centers like the one that caused the outbreak to obtain accreditation by a nationally recognized organization.

• Require physicians and their related businesses and centers to obtain accreditation before providing certain services involving anesthesia and sedation.

• Allow public agencies to investigate suspected infectious disease problems and to issue cease and desist orders if necessary.

• Ban retaliation and discrimination against nurses who report unsafe medical practices.

• Sanction medical facilities that fail to report “sentinel events” — those unexpected occurrences involving death or serious physical or psychological injury, or the risk of such outcomes.

Dr. Joe Hardy, a Republican state assemblyman and Henderson family physician, said the public has been a “driving force” in demanding the legislative changes.

“The public rightfully is insisting that we clean up our act,” Hardy said. “They trust us literally with their lives. For us to shortcut or to do something that would put them at risk — that flies in the face of reason and the Hippocratic oath.”

Richard Whitley, administrator of the Nevada State Health Division, said the proposed legislative changes are the outgrowth of the intense internal scrutiny in the wake of the outbreak. The event was a fork in the road, he said.

The health division had failed to conduct inspections of the clinic that caused the outbreak, so officials could have become defensive. But Whitley said the decision was made to analyze the system and propose improvements.

“The path of change is the one we went down and we went down it because we were obligated to,” Whitley said.

Leslie, who has been enmeshed in the response to the hepatitis C crisis because of her role on the health and human services committee, said there’s never been a year when the public’s trust in doctors and the medical profession has been more shaken.

Trust in the medical establishment was jarred by more than just the sloppy injection practices. Just a few years before the crisis Desai — a former president of the Nevada Medical Examiners Board — was one of the primary donors to the group Keep Our Doctors In Nevada, which successfully led a campaign to limit the amount of malpractice claims. The group ostensibly claimed to be helping the public by protecting physicians from litigious attorneys. But in fact, Desai was one of the founders of a malpractice insurance company that benefitted from the cap.

The doctors behind the malpractice cap had the public on their side and turned out to be some of the state’s “worst actors,” Leslie said. Now there’s been a dramatic shift in public opinion, she said.

“It’s a healthy reaction and probably appropriate that the pendulum swings back to the middle and makes sure we are adequately protecting patients,” Leslie said.

Legislators will now try to rebuild public trust by ensuring that safety standards are enforced through adequate inspections and punishment, Leslie said.

“We need to show the public we’re serious about this,” she said.

The crisis also has served to remind health providers of the importance of doing the little things right. Dr. Jim Christensen, a board member with the Southern Nevada Health District, which conducted the hepatitis C investigation, said he’s given thousands of injections without seeing a single bad outcome. So it’s easy to become desensitized to the routine, which from the consumer point of view is always a big deal, he said. The hepatitis C outbreak was so widespread that it shifted his point of view from the perspective of the doctor to that of the patient, he said.

“I would hope that this would focus all physicians to be better stewards of the responsibility that is given to us,” he said.

At Southwest Medical Associates, the primary medical practice for about 250,000 Clark County residents a year, the hepatitis C crisis led to the hiring a nurse who specialized in infection control, and the creation of a committee to examine the latest infection control literature and equipment manufacturer recommendations and make recommendations to management about policies and procedures. The changes were already in the works, said Chief Executive Michael Coleman, but the hepatitis C outbreak sped up the process.

“We want to make sure employees are engaged in compliance and view this as a learning experience,” Coleman said.

Matheis, who represents the doctors, said the reforms will never offset the horrors of the hepatitis C outbreak, but they are positive consequences that will protect people in the future.