VA Health Care

Lax infection-control practices and inadequate isolation rooms were behind the tuberculosis outbreak at the Department of Veterans Affairs (VA) medical center in East Orange, New Jersey. Medical center staff did not consistently use appropriate procedures for isolating suspected or known tuberculosis patients. The center lacked a comprehensive employee-testing program to monitor the staff's exposure to active tuberculosis. Isolation rooms did not have proper airflow, and air exhausted from these rooms may have contaminated other areas in the medical center. Since the outbreak, the center has made major improvements in its infection-control practices, and VA plans to construct 19 isolation rooms at the center. VA has also tried to beef up tuberculosis controls at its other medical centers and is giving greater scrutiny to centers' tuberculosis-control programs and practices. According to a December 1992 VA survey, 10 medical centers each had more than 20 cases of tuberculosis; six of the 10 also had the highest numbers of AIDS cases.

GAO found that: (1) the outbreak of tuberculosis at the East Orange VA Medical Center was a result of inadequate health management practices; (2) the medical center has developed a comprehensive corrective action plan that will enable it to increase tuberculosis awareness and make major improvements in identifying, isolating, and treating tuberculosis cases within its facility; (3) some of the 158 VA medical centers have workloads that are equal to or exceed that of the East Orange Center; (4) VA management initiatives include developing new infection-control policies and procedures, developing implementation plans, and improving oversight of centers' tuberculosis-control programs; (5) many non-VA and urban hospitals have recently experienced a resurgence of tuberculosis cases due to the transmission of the disease to patients and employees; and (6) non-VA and urban hospitals have implemented corrective actions in response to inadequate infection-control practices.