Schwarzenegger Replaces Most of State Nursing Board

California Gov. Arnold Schwarzenegger (John Moore/Getty Images)

Correction (July 14, 2009): This story incorrectly referred to former Board of Registered Nursing vice president Elizabeth O. Dietz as a professor of nursing at San Jose State. Although the board’s web site lists that as her current affiliation, the university said she retired in July 2008.

Update (July 14, 2009): Nursing Board Executive Officer Ruth Ann Terry Resigns [1]

Gov. Arnold Schwarzenegger replaced most members of the California Board of Registered Nursing on Monday, citing the unacceptable time it takes to discipline nurses accused of egregious misconduct.

He fired three of six sitting board members [2] – including President Susanne Phillips [3] – in two-paragraph letters curtly thanking them for their service. Another member resigned Sunday. Late Monday, the governor's administration released a list of replacements.

The shake-up came a day after the Los Angeles Times and ProPublica published an investigation [4] finding that it takes the board, which oversees 350,000 licensees, an average of three years and five months [5] to investigate and close complaints against nurses.

During that time, nurses accused of wrongdoing are free to practice – often with spotless records – and move from hospital to hospital. Potential employers are unaware of the risks, and patients have been harmed as a result.

Reporters found nurses who continued to work unrestricted for years despite documented histories of incompetence, violence, criminal convictions and drug theft or abuse. In dozens of cases, nurses maintained clean records in California even though they had been suspended or fired by employers, disciplined by another California licensing board or restricted from practice by other states.

"It is absolutely unacceptable that it takes years to investigate such outrageous allegations of misconduct against licensed health professionals whom the public rely on for their health and well-being," Schwarzenegger said in a written statement.

Board member Andrea Guillen Dutton, in a resignation letter Sunday [6], said she was leaving in frustration. "Certain ‘bad actors' are jeopardizing the reputation of the entire nursing profession," she wrote. "This deeply saddens me."

"I have fought to defend the integrity of patient care throughout the state by holding the negligent accountable," she wrote. "However, I have grown increasingly frustrated by the board's lack of ability to achieve its stated objectives in a timely and efficient manner."

Besides Phillips, the other fired board members were vice president Elizabeth O. Dietz, a former professor of nursing at San Jose State, and Janice Glaab, a public affairs consultant.

Schwarzenegger's action Monday fills two of three vacancies on the board [2] and replaces four of the board's sitting members – all of whom had been appointed by him.

The two remaining members are Nancy L. Beecham, appointed by the governor in 2006, and Dian Harrison, who was appointed last year by Assembly speaker Karen Bass.

Neither Beecham nor Harrison could be reached late Monday, nor could any of the departing board members.

Schwarzenegger's statement said his "administration is dedicated to protecting public health and safety, and the new board will act quickly and decisively to achieve that goal."

Fred Aguiar, secretary of the State and Consumer Services Agency, said in an interview that the new board would be asked immediately to come up with a plan to eliminate the case backlog. "This plan needs to include how many more investigators are needed, how much that will cost. … I want to know now."

California Board of Registered Nursing executive officer Ruth Ann Terry (Liz O. Baylen/Los Angeles Times)

The governor's decision does not directly affect the standing of Ruth Ann Terry, who has been the board's executive officer for nearly 16 years and a staff member for 25. Only the board has the power to hire and fire the executive.

Terry, reached late Monday, hung up on a reporter, saying, "We don't have anything to say."

But Aguiar suggested Monday that Terry and other staffers could be vulnerable. The governor "supports the new board in its commitment to protecting patients – and if that means cleaning house, including board staff, so be it," he said. "The days of excuses and status quo are over. It's broken and we're going to fix it."

The Times and ProPublica

In an interview last week, Terry acknowledged that the system needed to be "streamlined" but blamed other parts of the state's bureaucracy for delays.

Early Monday, Terry and her assistant executive officer, Heidi Goodman,

"Ruth and I are aware of the grim picture painted by this article," they wrote, "however, the board members, managers and supervisors know that you work very hard to carry out the mission of the board to protect the healthcare consumers in California and we appreciate all that you do."

Presented with the investigation's findings Thursday, board President Phillips, a family nurse practitioner and associate clinical professor at UC Irvine, said she supported Terry "absolutely – without question."

"The issue of patient safety is of the utmost importance to this board," she said. "It's not that we are ignoring a situation where there are delays. We absolutely are not."

Questions about the board's leadership were first raised last fall

In addition to the governor's action, the state Senate Business and Professions Committee, which has jurisdiction over the board, plans to hold a hearing next month to address the issues raised in The Times' article.

The committee will look at introducing legislation that would appoint an "enforcement monitor" to evaluate the board's discipline process and make recommendations, said Bill Gage, the committee's chief consultant. Such a monitor was appointed at one time to work with the Medical Board of California, which regulates the state's doctors.

Consumer advocate Ken McEldowney said the board members need to do more than just fill seats.

"The leadership is key," said McEldowney, executive director of Consumer Action, a San Francisco-based national consumer advocacy and education membership organization.

"It just appears to me that they don't care."

The six new board members are: Ann Boynton, 47, of Sacramento, a former undersecretary for the Health and Human Services Agency; Judy Corless, 58, of Corona, a clinical nursing director at the Corona Outpatient Surgical
Center since April 2009; Jeannine Graves, 49, of Sacramento, a staff nurse for the Capitol Surgical Associates and the Mercy San Juan Medical Center; Richard Rice, 60, of Imperial Beach, a former chairman of the Unemployment Insurance Appeals Board; Catherine Todero, 57, of La Mesa, director of the school of nursing at San Diego State University and a professor there; and Kathrine Ware, 50, of Davis, a nurse practitioner for the Vascular Center Clinic at the University of California Davis.

These positions do not require Senate confirmation, and the compensation is $100 per working day.

[8] when The Times and ProPublica reported that nurses with serious or multiple criminal convictions kept their licenses for years before the board acted against them. As a result, the board now requires every nurse to submit fingerprints [9], which can be matched against arrest records. Renewing nurses must also disclose any convictions or discipline by other states.sent an e-mail to all board staff members encouraging them not to lose heart [7].found that the board relied heavily on Terry and her staff [4]. At five public meetings attended by reporters since November 2007, Terry never focused on the delays in disciplining errant nurses. Neither did board members, even though they must vet all disciplinary actions.

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Possible breast surgery cases may be one result of heightened vigilance

By Marshall Allen

The number of suspected infections reported by Southern Nevada health care providers has increased significantly in recent months, probably because they are more vigilant after last year's hepatitis C crisis, the state's medical epidemiologist says.

Case in point: A reported cluster of 16 possible infections related to breast expander surgeries in Las Vegas has triggered a multiagency probe that's being led by the Southern Nevada Health District, the organization that investigated the hepatitis C outbreak.

Breast expander procedures generally follow a mastectomy, serving to expand breast tissue over time in order to insert an implant. An expander can be likened to a balloon, and after insertion it is filled with incremental additions of fluid to expand the space where the implant will rest.

It's rare to observe a cluster of possible breast expander infections, said Dr. Ihsan Azzam, the state medical epidemiologist, who works for the Nevada State Health Division. Azzam said the investigation is in its early weeks, so it's unclear whether there is an actual outbreak or a false positive — as is the case with many reports of observed infections.

What is clear is that health providers are attuned to the potential that diseases are being spread in Las Vegas health facilities, which Azzam says is a good thing.

"This is a clear example that new partners are coming aboard," Azzam said of the more responsive medical community. "People are more aware and conscious. People are reporting everything. Since the outbreak of hepatitis C, we have a significantly larger number of reports from doctors, nurses, physician assistants ... That really helps me."

There are so many variables that it could take weeks to understand the cause of the possible breast expander infections, which have been observed at multiple hospitals, sources said. University Medical Center is one of the locations.

UMC officials said the potential problem was identified by an admitting technician who had a gut feeling there were an unusually high number of women coming to the hospital with breast-related infections. The technician turned over a list of 15 patient names to the hospital's infection control department, which began an internal investigation to determine any common links.

Dr. Alan Greenberg, medical director of UMC's infectious disease department, said he typically sees two or three of the same type of infections in a given year, and that not all 15 initial UMC cases involved breast expander procedures. The UMC investigation, which is ongoing, has confirmed three cases of breast expander infections and one related to a breast augmentation procedure. One of the infections came after the patient suffered trauma at the site, he said.

Greenberg said there are no known links between the procedures at this time, "but because everyone is on heightened alert and there's a more frequent admission rate for this diagnosis than in the past, we noticed."

Greenberg said he has contacted surgical groups in Las Vegas that perform the procedures and they have been cooperative — checking to see whether they've changed any techniques or implant materials. He said the emphasis on infection prevention is standard in hospitals, which is different from the outpatient clinic that caused the hepatitis C outbreak, which has no such structures in place.

A review of medical literature shows that infections can be a complication in a small percentage of breast expander procedures. The initial challenge, Azzam said, is to confirm that the women involved have actual infections and not some other problem, such as dead tissue. Then it will be a matter of going step-by-step through the process of each procedure to determine any common factors that could have caused an infection. Because there are many variables — the type of device, facility where the operation took place, staff involved, location of follow-up appointments and more — determining the source of the infection is a challenge, Azzam said.

A source familiar with the investigation said a single surgeon may be a common link among patients who suffered complications. The surgeon did not return the Sun's phone calls. Other doctors told the Sun that the same surgeon performing the procedures shouldn't suggest he is to blame.

UMC officials said each patient had multiple doctors, so it's too early to say whether one was in common.

Officials from the Southern Nevada Health District confirmed they are investigating the infections, but would not comment on the situation.

"It's so fluid we don't really know what it is," a Health District official said. "It's really preliminary."

The Centers for Disease Control and Prevention is assisting in the investigation.

Hospitals and nursing homes remain the bug's prime breeding ground, with patients with weakened immune systems being most vulnerable. Critically ill patients are at particular high risk, in part because of the number of invasive procedures that they require in the intensive care unit (ICU).

In some prior studies, washing with tea tree oil has been shown to be effective in removing MRSA on the skin.

Therefore, Blackwood and colleagues are evaluating the effect of daily washing with a 5 percent tea tree oil preparation on new MRSA infections among ICU patients. The 5 percent tea tree oil wash is being compared with a standard body wash (Johnson's Baby Softwash).

"We started this trial in November 2007," Blackwood said. "We aim to complete it in November 2010."

If tea tree oil body wash proves effective against MRSA, widespread implementation of such a simple prevention tool has the potential to improve patient outcomes and reduce healthcare costs, the researchers say.

Copyright 2009 Reuters.

URL: http://www.msnbc.msn.com/id/28473019/from/ET/

MRSA colonization common in emergency department personnel

By Will Boggs, MD.

NEW YORK (Reuters Health) - Health care workers in emergency departments are often carriers of the methicillin-resistant Staphylococcus aureus, or (MRSA), potentially putting patients at risk, according to two reports in the Annals of Emergency Medicine.

Testing positive for MRSA is sometimes transient among health care workers, but unfortunately the results of this study, along with the findings of the second report, reinforce concerns that MRSA carriers are an important part of the transmission of MRSA among patients, Dr. Elise O. Lovell from Advocate Christ Medical Center, Oak Lawn, Illinois, told Reuters Health.

Lovell and colleagues collected nasal swabs from a sample of 105 emergency department staff at their institution. Sixteen subjects (15 percent) tested positive for MRSA, including 12 nurses, 2 physicians, and 2 technicians.

The MRSA positivity rates in our emergency department health care workers is "much higher than that found in the general US population, but is similar to rates seen in other studies of non-ED medical personnel," Dr. Lovell said.

In the second report, Dr. Brian P. Suffoletto and colleagues from the University of Pittsburgh Department of Emergency Medicine measured the prevalence of Staphylococcus aureus and MRSA in 255 emergency department health care workers.

Just under one third of nasal cultures (31.8 percent) were positive for S. aureus, the researchers report, and the overall prevalence of MRSA 0was 4.3 percent.

None of the demographic and exposure characteristics examined were significantly associated with MRSA colonization, the investigators say, but MRSA colonization was restricted to nurses, nursing assistants, and radiology and respiratory technicians.

"The varying prevalence among the different health care workers was unexpected," Suffoletto told Reuters Health.

The relationship between MRSA-positive ED personnel and patient transmission is "still largely unexplored," Suffoletto continued. First we will need to establish if MRSA in ED personnel is transient or persistent. "Then we wish to determine the rate of unprotected contacts between ED personnel and patients.".

Both Lovell and Suffoletto stressed the importance of using universal infection control practices in the emergency department.

"It's been demonstrated repeatedly that these hygiene techniques are poorly followed in the ED, yet they represent the best (and simplest) way to minimize the spread of MRSA between our patients and to keep our patients and ourselves safe," Lovell said.

"The findings in these reports may have important implications for infection control practice," agrees Dr. John A. Jernigan from the U.S. Centers for Disease Control and Prevention, Atlanta, writing in a related editorial.

"Better implementation of current recommendations for preventing transmission of MRSA and other multidrug-resistant organisms will likely yield important benefits for both patients and health care personnel."

SOURCE: Annals of Emergency Medicine, November 2008