Attorney Daily - Your source for the most important legal news

On July 24, 2008, Southern Nevada Health District official announced that genetic testing has traced seven hepatitis C infections to two patients who underwent procedures at the Endoscopy Center of Southern Nevada last year.

Brian Labus, Health District Senior Epidemiologist, said one of the sources underwent a procedure July 25 and the other Sept. 21. The Sept. 21 patient was a known carrier of hepatitis C, meaning both the health care provider and patient knew the virus was in the patient’s bloodstream at the time of the procedure.

It was unclear if the source from July 25 was a known carrier, Labus said at Thursday’s meeting. “We know when it started and where it went,” Labus said, referring to the transmission of hepatitis C to seven former patients of the facility at 700 Shadow Lane on those two dates.

Six people have tested positive who underwent procedures at the clinic on Sept. 21. One tested positive following a July 25 visit. An eighth hepatitis C case has been linked to the clinic based on a procedure in 2005.

Health officials now will concentrate on determining how many more of the Shadow Lane facility’s 50,000 patients may have been exposed during procedures between March 2004 and Jan. 11. That is the time frame in which health officials believe it was common practice among nurse anesthetists at the Shadow Lane facility to reuse single-dose vials of medication and syringes.

The number of acute hepatitis C cases linked to the clinic probably will remain at seven, unless the health district receives a report by the end of the month, Labus said.

Acute hepatitis C occurs when someone becomes ill within six months of exposure. July 11 marked the last date a former patient of the endoscopy center would have developed acute hepatitis C, based on a Jan. 11 exposure date.

“Within the next week or so, we should be done with getting acute cases,” Labus said.

Chronic hepatitis C cases are a different story. In such cases, a patient won’t become symptomatic within the incubation period, and the disease usually isn’t identified until years after exposure.

Seven of the eight cases linked to the Shadow Lane facility are acute. The eighth case, which was announced is a chronic case.

“This person had no symptoms,” Labus said. “They wouldn’t have known they had it unless they had been tested.”

The remaining case is linked to an affiliated clinic on Burnham Avenue.

Dr. Dipak Desai, a Las Vegas gastroenterologist, is majority owner of both clinics, which were closed shortly after the outbreak was announced.

County prosecutors will fold the new hepatitis case into the ongoing criminal investigation, Deputy District Attorney Scott Mitchell said.

The investigation was hindered by a wall of silence by the clinic’s nurse anesthetists, who will be key witnesses in any prosecution, Mitchell said.

The lack of cooperation changed in recent weeks when prosecutors subpoenaed the nurses to testify before an investigative grand jury, he said.

“We have broken through that wall,” Mitchell said, adding that some nurse anesthetists now are cooperating with investigators.

The grand jury also helped separate potential witnesses from potential defendants, allowing investigators to “whittle down the case against core people who we have good evidence against,” he said.

The investigation will probably continue for a couple of months before any charges are filed, Mitchell said.

Desai and one of his partners, Dr. Eladio Carrera, have had their licenses suspended pending an investigation by the Nevada Board of Medical Examiners. The board has scheduled hearings for Desai and Carrera in September and October.

Both performed procedures at the Shadow Lane facility on July 25 and Sept. 21, dates when CDC and health district investigators believe nurse anesthetists contaminated single-dose anesthesia vials with syringes that were reused.

One nurse anesthetist told CDC investigators that the clinic’s staff had instructed him to reuse syringes and single-dose vials of propofol, a fast-acting sedative.

Debra Scott, executive director of the Nevada State Board of Nursing, said 36 complaints have been filed against nurses affiliated with the endoscopy center.

Hearings have been scheduled for Oct. 22 and 23. However, Scott said, the regulatory board has not filed any charges against nurses.

She said complaints or charges brought by the nursing board could be filed 30 days in advance of the hearing.

“We have evidence at this point that there are witnesses willing to come forward saying some of the CRNAs used single-dose vials for more than one patient,” she said.

The nursing board still needs some reports from law enforcement to complete its investigation, Scott said.

Six nurse anesthetists with ties to the Shadow Lane facility have voluntarily surrendered their licenses.

Health officials also announced that a hepatitis C registry launched by the health district last month is making progress. So far, 6,000 patients have responded to the registry.

The registry was launched in an effort to reach more of the clinic’s population to identify those who may have been exposed.

During the July 24, 2008 meeting, Dr. Joe Hardy asked if any former patients of the Shadow Lane facility had tested positive for hepatitis B or HIV, the virus that leads to AIDS.

Labus said they had not.

“That would be called good news,” Hardy said.

A federal report released on May 16, 2008 highlights that six patients who tested positive for acute hepatitis C just weeks after undergoing procedures at a Las Vegas clinic received anesthesia from one of two nurses who reported routinely reusing syringes and medication vials.

One of the nurse anesthetists told health investigators that the practice of reusing syringes and single-dose vials of propofol a fast-acting sedative “reflected what clinic staff had instructed him to do,” according to the report by the Centers for Disease Control and Prevention.

The other nurse, who was no longer employed by the clinic at the time of the CDC visit, was interviewed by telephone and reported similar practices.

The CDC concludes, as did the Southern Nevada Health District and the Nevada State Health Division, that unsafe injection practices probably resulted in six people contracting hepatitis C at the Endoscopy Center of Southern Nevada on July 25 and Sept. 21 of last year. The nurses would use a syringe on an infected patient, and then reuse the syringe to draw medication for the patient, contaminating the medication vial for patients down the line.

An investigation by health authorities that began in early January led to the largest patient notification in U.S. history. About 50,000 former patients of the 700 Shadow Lane facility are urged to get tested for hepatitis and HIV. Tens of thousands of tests have been administered, with about 400 people testing positive. Health authorities have linked 84 of these cases, seven of them acute cases, to the closed medical clinic. An eighth acute case has been linked to a sister clinic.

The CDC sent officers from its Division of Viral Hepatitis and Division of Healthcare Quality Promotion to Las Vegas on Jan. 9 to assist with the investigation. CDC and health district investigators spent nearly a week observing procedures at the endoscopy center.

Among other unsafe practices, CDC investigators observed clinic staff “not performing proper or adequate hand hygiene between patients.” In some cases nurse anesthetists were seen not using gloves. One nurse anesthetist was seen “moving about the room with an uncapped needle.”

Nurses also were observed pre-filling syringes with lidocaine, recapping the needles and storing them in a drawer without labeling or dating them, the report says.

All of the improper infection control practices were pointed out to staff.

The CDC also instructed the clinic’s staff not to reuse detergent solution on multiple endoscopes. However, despite identifying problems with the cleaning of endoscopes, neither the CDC nor the health district linked infection transmission to the actual procedures and equipment.

The same two nurses also were responsible for giving anesthesia to a known carrier of chronic hepatitis C on each of the two dates at issue. Those patients are thought to be the sources of infection for patients treated after them.

According to the CDC report, the six patients ranged in age from 37 to 72.

Four of the five patients on Sept. 21 have been linked genetically to the potential source, health officials say. Blood results are pending on the fifth patient. Genetic testing has yet to be done on the July case.

Brian Labus, senior epidemiologist for the health district, said roughly 120 people had procedures on those two days. No other patients treated on those days have tested positive for hepatitis C, he said.

Debra Scott, executive director of the Nevada State Board of Nursing, said the CDC’s report offers new details about nurse involvement in the outbreak. The report also identifies two nurses who knew of the unsafe infection control practices but did not report them. This failure could result in disciplinary action being taken against the nurses, Scott said.

The CDC in its report identified four nurses. The other two nurses were not observed reusing syringes. However, one of them admitted, “having been instructed to reuse syringes to administer multiple doses of propofol to an individual patient, but did not do so,” the report states.

Scott said she has heard that some nurses who worked at the clinic might be remaining silent out of fear they’ll be disciplined.

“We really didn’t know who knew what and who actually witnessed the misconduct,” Scott said. “What we’re trying to figure out is where in the hierarchy did communication break down about standard practices.”

The CDC’s report doesn’t identify who instructed nurses to reuse syringes and single-dose medication vials.

When the city of Las Vegas revoked the business licenses of the Shadow Lane facility and its affiliated clinics, the head of the licensing division said investigators learned that some doctors, including majority owner Dipak Desai, had ordered nurses to reuse syringes and single dose vials of propofol.

Either Desai or Dr. Eladio Carrera, a part owner of the endoscopy center, treated the six patients who had procedures on July 25 and Sept. 21. The two have had their medical licenses suspended pending the investigation.

Six nurse anesthesists have voluntarily relinquished their licenses.

On May 16, 2008, federal health officials announced that workers reused syringes and medicine vials at a Las Vegas clinic caused a recent Hepatitis C outbreak in Nevada. The Centers for Disease Control and Prevention was contacted by state health officials earlier this year after two people treated at the now-closed Endoscopy Center of Southern Nevada were diagnosed with hepatitis C.

Officials have linked 84 cases of the liver disease to the clinic after notifying 50,000 patients of the clinic to be tested.

CDC investigators said in a report to the Nevada State Health Division that during visits to the clinic, they saw employees reusing syringes to give a sedative and that interviews suggested it was common practice.

“This was considered the most likely mode of transmission,” the report said.

The CDC said the same syringe was used for an individual patient if more sedative was needed. Backflow into the syringe from an infected patient could have contaminated the sedative vial. The virus could have been passed along from the contaminated vial when it was improperly used for the next patient, the CDC said.

About 400 former patients of the center tested positive for hepatitis C but officials have determined that most could have contracted the virus through other means, including intravenous drug use, blood transfusions, organ transplants or kidney dialysis, receiving blood clotting agents before 1987, or sexual contact with a person with hepatitis C.

Hepatitis C results in the swelling of the liver and can cause stomach pain, fatigue and jaundice. It may eventually result in liver failure. Even when no symptoms occur, the virus can slowly damage the liver.

Doctors Dipak Desai and Eladio Carrera, whose Nevada medical licenses have been suspended pending state Board of Medical Examiners hearings, headed the Endoscopy Center and several other clinics.

Las Vegas police have seized medical records from the clinics, and the FBI, the state attorney general and the Clark County district attorney are involved in a criminal investigation. The owners of the clinics have surrendered business licenses and paid $500,000 in fines.

Since 1999, the CDC counts 14 hepatitis outbreaks in the U.S. linked to bad injection practices.