'Serial infector' charged in hospital HCV outbreak

CMS: Secure narcotics, use precautions

It began as an infection control nightmare in New Hampshire, but it didn't stop there. A medical technician who worked in the cardiac catheterization lab in Exeter Hospital in Nashua was charged with diverting drugs and reusing the syringes on patients. He is hepatitis C positive, and at least 30 patients have new HCV infections that are linked to his strain, investigators report.

The accused, David Kwiatkowski, was dubbed a "serial infector" by federal prosecutors because he worked for an agency that sent health care workers to hospitals around the country. Kwiatkowski has denied diverting drugs. The medical technician worked at some 13 hospitals in eight states: Arizona, Georgia, Kansas, Maryland, Michigan, New York, Pennsylvania and New Hampshire. Investigations are proceeding at the other locations.

The case highlights the importance of pre-employment background checks and raises the issue of random drug testing of health care workers. It also underscores the risk of transmission of hepatitis C in health care settings, either through intentional drug diversion or infection control lapses, such as reuse of single-dose vials.

Between 2008 and 2011, the Centers for Disease Control and Prevention received reports of 31 outbreaks of hepatitis B or C in a health care setting, with about 250 people infected and about 88,000 patients tested. In the Exeter case, eventually more than 4,000 patients will have been tested.

Hospitals can take steps to improve both infection control and narcotics control, says New Hampshire state epidemiologist Sharon Alroy-Preis, MD, MPH.

"It's important for every hospital to look at their own processes," she says. "Who has access to narcotics? What is the process of preparing and administering narcotics? It's important to make sure those are very tight. You can minimize [the possibility of] drug diversion."

Cath lab was common link

The Exeter case came to light on May 6, with a report to public health authorities of a cluster of four people with newly diagnosed acute hepatitis C. "It became clear that the common link between all of them was the cardiac cath lab," says Alroy-Preis.

In the investigation, "we decided the most likely method was drug diversion," she says. "In other hepatitis C outbreaks in the past, there have been infection control problems — specifically with using a single dose vial on multiple patients, reusing syringes — that we did not find in this case."

In an investigation, it came out that a co-worker had complained on one occasion that Kwiatkowski's eyes were blood shot and he seemed to be "on something." Other employees noted that Kwiatkowski would come into the cardiac cath lab when he wasn't on call, and that he appeared to be sweaty and shaky.

"In every case, concerns raised by hospital staff were evaluated, in one instance including the involvement of the hospital's human resources team," the hospital said in a statement. "In each of these few instances, Kwiatkowski provided plausible explanations related either to medical issues he had previously made claims about, or to family crises."

Thomas Wharton, MD, FACC, medical director of the Cardiac Catheterization Unit, called Kwiatkowski "the ultimate con artist."

"David had stories for everything that pulled at your heart strings and we had no reason to disbelieve him," Wharton said in a statement. "David claimed to have several important medical conditions, and we had no reason to challenge this. The day he reportedly arrived to work with red eyes he told us his aunt had died the night before and he had been up all night crying."

Exeter Hospital says that Kwiatkowski had pre-employment drug testing, a national and state criminal background check, and a federal sanctions check before he began working. He also had favorable recommendations.

However, that background check did not pick up the fact that Kwiatkowski had been fired from an Arizona hospital in a case of suspected drug diversion.

Coming to a hospital near you?

What can be done to prevent such situations from happening at other hospitals? The Patients Speak, a group of victims from this outbreak, is pushing for mandatory drug testing at hospitals and a national registry or national certification for licensed health care professionals.

"It's an incident waiting to happen at a hospital near you because the proper protocols, the proper legislative efforts, and the proper regulatory efforts are not in place," says Elenore Casey Crane, a former state representative from Nashua who co-founded The Patients Speak with Domenic Paolini, a former cardiac surgeon who is a Boston-based malpractice attorney and has filed a class action suit on behalf of patients.

"You have people who work at Home Depot being scrutinized more than people who work in an operating room, which is crazy," says Paolini. "If the staffing company and the hospital had done their due diligence — if they had called places where he had worked, if they had called places where he claimed to receive diplomas — it would have come out that there were problems."

The Center for Medicare & Medicaid Services (CMS) conducted a survey at Exeter and cited the hospital for failing to sufficiently secure controlled medications. CMS also cited the hospital for lax infection control.

The hospital "failed to provide a sanitary environment and avoid sources of transmission of potential infections" and failed to have adequate policies and procedures, "allowing an employee with draining wounds to participate in an environment where invasive procedures were being performed," CMS said. (According to news reports, this employee with draining wounds was Kwiatkowski.)

A CMS surveyor also reported observing a physical therapist who was not wearing gown or gloves despite close contact with a patient on contact precautions.

In response, Exeter Hospital said it took additional steps to secure pain medications and re-educated staff about appropriate personal protective equipment.

Crane is looking beyond procedural changes for a cultural change that encourages hospitals and health care workers to root out incompetence and drug abuse.

"We could have stopped him, and we can't let it happen again," she says. "The only way we're going to prevent this to happen to someone in a hospital near you is to put something in place that allows for tracking of the bad apples. I do believe there's a culture of secrecy and cover up."