Ex-staffer says hospital hid risks to 2 patients

A Council Bluffs hospital administrator resigned his post last year after his superiors refused to tell patients that surgical instruments used on them were dirty and hadn't been properly sterilized, documents show.

Robert Owen Burgin, a registered nurse who worked as the infection-control specialist for Mercy Hospital in Council Bluffs, resigned April 12, 2013. State records show he quit after making several attempts to obtain permission to tell two surgical patients they were at risk of infection from blood-borne pathogens because of unclean surgical instruments used during their operations.

When Burgin continued to press the matter, his supervisor allegedly instructed him to be "a team player" and said that if he persisted in pursuing the matter it would be difficult for him to keep his job.

Mercy Hospital officials declined to comment on the matter Friday, but hospital representatives testified at a recent unemployment hearing that while Burgin raised "legitimate concerns," and changes in operating-room procedures were needed, no patients were ever put at risk.

National studies indicate that on any given day, at least one of every 25 patients in U.S. hospitals is dealing with an infection acquired during treatment. Those infections are believed to contribute to 99,000 patient deaths each year.

The Mercy Hospital matter became public because Burgin filed for unemployment benefits and the hospital, which is owned by Catholic Health Initiatives, challenged that claim. That led to a public hearing at which Burgin and hospital officials testified under oath about the circumstances surrounding Burgin's resignation.

Last week, Administrative Law Judge Terence Nice ruled in favor of Burgin, saying the nurse "felt intimidated to stop his activities in behalf of the patients" and had resigned his position for good cause as a result of the hospital's actions.

Burgin testified that he became aware of the two operating-room incidents in late 2012 after overhearing a conversation between hospital staffers. He made inquiries and discovered there were six surgical cases in which patient health might have been compromised. Two of the cases could be confirmed, he said.

Hospital records introduced as exhibits during the unemployment hearing indicate the first case involved the removal of a patient's spleen on Oct. 24, 2012. The second case involved a Dec. 2, 2012, operation. An incident report about that operation indicates that one hour into the procedure, the surgical staff realized there was blood from a previous patient on one of the instruments. "This instrument was already used on the patient; now case (is) contaminated," the report says.

Burgin testified that after reviewing the records, he repeatedly argued for full disclosure to the two patients so they could contact their doctors and arrange for blood tests and physician monitoring of surgical sites. He said he told his supervisor, Quality Director Christine Daley, that Mercy's written policy called for the staff to inform patients of any error that didn't cause immediate harm but created a need for monitoring and intervention.

"I was told on two different occasions by Chris Daley that I needed to back off," Burgin testified. "And one particular time, Chris Daley stated to me, in her office, that if I continued down this path — and I quote — 'we both know where this is going.' And at that time, I said, 'Are you threatening to fire me?' She did not reply to that question. She did state that … working for her was going to be very difficult if I kept pursuing the fact that they needed to notify these patients. … She also told me (Mercy) was one of the largest health care employers in the area and that I would be blackballed from getting a job as a nurse in this area."

Burgin said he reported the matter to higher-ranking hospital officials and to Mercy's ethics committee, Iowa Medicare and the national organization that accredits most U.S. hospitals. He was subsequently told the patients would not be informed of what happened.

A short time later, Burgin gave Daley a letter of resignation in which he wrote: "You will recall that during the last five or six months, I have met with you regarding the two surgical cases where a breach in sterile technique took place. … The genuine surprise was that instead of following Mercy's policy, the decision was made to not tell the patients. Two years ago, this (same type of incident) happened and the patient was not notified, either. That never sat well with me and has bothered me to this day. I have experienced a moral and ethical dilemma over the last six months trying to advocate for the patients in these cases, and regrettably have come to the conclusion that I cannot continue to be Mercy's infection preventionist."

At Burgin's unemployment hearing, Mercy's human resources director, Jennifer Smith, testified that if Burgin was unhappy about the hospital's response to his concerns, he had options other than resigning.

"Owen could have talked with the Corporate Integrity Hotline, but he could have also come to human resources if he had some concerns," she said.

Daley testified that after Burgin came to her with his concerns, she concluded that "we definitely need to improve some processes in the operating room." But she said a specialist in infectious diseases, as well as other medical professionals such as the hospital's chief quality officer, campus medical director and the Physician Quality Committee chairman, concluded there was no risk whatsoever to the two patients.

Burgin said Friday that he had yet to find another job but is looking at a nursing position in Oklahoma.

"This has been a huge hardship for me, but a lot of times doing the right thing is not the easy thing to do," he said. "I've had to cash in my retirement funds to live on and to put food on the table. But I've spent 20 years as a volunteer firefighter and an EMT, and I took my job as a patient advocate very seriously. It was not just a job. It was much more than that. Giving back to the community and helping people is something that has always been very important to me. And I will say that 99 percent of the people at that hospital are so dedicated to what they do."

Burgin said one of his main concerns at the hospital was that one surgical pack for an operation could include as many as 1,000 instruments, and the workers who sterilized them were overworked and undertrained.

"I don't think any of them had anything other than a high school diploma," he said. "And this is not to disparage them, because they have hearts as big as Texas, but some of them had real trouble reading. That was a problem. They couldn't even take the test to get special certification."

He said instrument sterilization and hospital-acquired infections are a major problem nationally.

"The technology exists to do this right, but so many hospitals would rather spend the money on fountains or valet parking," he said.

Based on 2007 data, the Centers for Disease Control and Prevention estimates that each year, 1.7 million patients contract infections while being treated in doctors' offices, hospitals or nursing homes. In 2012, a study of acute-care hospitals concluded that surgical-site infections in those facilities accounted for almost 22 percent of all hospital-acquired infections.