Healthcare Inspection – Potential Exposure to Creutzfeldt-Jakob Disease, VA Connecticut Healthcare System, West Haven, Connecticut

OIG conducted an oversight review regarding potential exposure of two veteran patients to Creutzfeldt-Jakob Disease (CJD) at the VA Connecticut Healthcare System (facility), West Haven, CT. We reviewed the facility’s procedures for reprocessing of neurosurgical instruments, handling and tracking of loaner instrument trays, and responding to the potential exposures and the follow-up actions taken post-exposure. In addition, we reviewed Veterans Health Administration (VHA) reprocessing requirements for neurosurgical instruments. We concluded that the facility took appropriate steps to address potential patient exposure to CJD. Managers were proactive in seeking counsel from subject matter experts within the VA and other Government agencies to ensure that proper patient follow-up and notification occurred in a timely manner. Facility providers notified and met with the involved patients and/or their family members to discuss the potential exposure to CJD, the risks of CJD transmission, and answer questions or concerns. Providers documented clinical disclosures in the patients’ electronic health records. Although the facility met the recommended manufacturer’s minimum requirement for sterilization of surgical instruments, the facility amended its process by increasing sterilization time from 4 to 18 minutes for neurosurgical instruments. Additionally, managers implemented a process for tracking all loaner instruments from receipt to return. We concluded that VHA had appropriate policies and procedures for reprocessing neurosurgical instruments. We made no recommendations.