UW Hospital Discovery Raises
The current push for health care reform has its origins in more than a few events and circumstances, including a devastating 1999 report on hospital errors.
While I'm not prepared to characterize what happened recently at UW Hospital as a medical error, the incident raises "best practice" questions.
To summarize: The hospital has notified 53 patients that they face an extremely low risk of contracting a deadly brain disorder called Creutzfeldt-Jakob disease (CJD). In a recent 40-day period, the patients were operated on with surgical instruments that are believed to be contaminated with the disease during a June 2009 operation to remove a brain tumor from another patient, a woman who died of CJD on July 21.
The hospital had been using normal sterilization procedures on the affected instruments, but now intends to use heightened sterilization guidelines prescribed by the Centers for Disease Control and Prevention. Hospitals that use disposable instruments during brain surgery have the option of destroying those instruments in cases where the patient was suffering from CJD. (A previous version of this blog suggested that some hospitals routinely destroy instruments after such surgeries, but that's not the case; UC-San Francisco destroys disposable instruments, and a UW Hospital spokeswoman said UW would do the same thing if such instruments were used.)
The heightened sterilization sounds pretty effective. As part of the process, the instruments are soaked in sodium hydroxide for an hour and then heated to 250 degrees Fahrenheit for an hour. But there still is some question about whether any process can completely rid the instruments of all prions — those infectious pathogens that cause a number of fatal neurodegenerative diseases.
The heightened sterilization method, the UW hospital spokeswoman assures me, is the "best practice" once you have confirmed a case of CJD.
The good news is that the risk of these 53 patients contracting CJD is extremely low — "infinitesimal," according to Dr. Carl Getto, UW hospital's chief medical officer. Let's hope so because those patients will be living with some fear for the rest of their lives. CJD might be rare, but because it's characterized by rapidly progressing dementia, it can kill fairly quickly.