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'Serial Infector' Investigation Points to Need for Federal Registry

 |  By cclark@healthleadersmedia.com  
   August 02, 2012

He's being called a "drug diverter," a "serial infector," and the "Typhoid Mary" of New Hampshire's Exeter Hospital.

But the big question healthcare leaders may now be sweating is how a hospital employee or contractor  could so easily hop through hospitals in nine states and "recklessly" infect at least 30 patients with a potentially lethal virus, as federal authorities allege radiology technician David Matthew Kwiatkowski did.

And what others might still be out there, stealing filled syringes in acute care settings, using and infecting them, then returning them for patient care?

If you're an addict wanting to stay high, you'd look to healthcare for a job. Why? With apologies to Willie Sutton, because that's where the narcotics are. 

Kwiatkowski was reportedly axed by two of those hospitals before he even got to Exeter. Yet nobody tried to stop him.

A national problem

"This is a huge issue for the nation," says Jose Montero, MD, director of the New Hampshire Division of Public HealthServices who leads his agency's investigation of Exeter Hospital, where Kwiatkowski worked for more than a year. Montero has been looking into the mess for three months so far, and officials from the Centers for Medicare & Medicaid Services and several other federal agencies are investigating as well.

That there is no national requirement that all hospitals and states must report such individuals makes Montero so angry, he pauses the interview to apologize, "for getting on a soapbox."  Instead of a uniform registry, there's a patchwork of state-by-state autonomy, he says.

"Each state has the capability to determine a lot of things that impact the population of that state," he continues.  "But we are missing the point.  Having different requirements for licensing in different states is too haphazard.

"When you look at the affidavits and the criminal information that has been disclosed out there, and how he was able to move from state to state...this just shouldn't have happened."

On July 19, the New Hampshire U.S. Attorney's Office charged Kwiatkowski with fraud and drug diversion related to the theft of syringes filled with the anesthesia drug fentanyl intended for cardiac catheterization patients and injecting them in himself. According to the indictment, Kwiatkowski would then replace "the drug in the syringe with another liquid (such as saline), which is then injected into the patient."

30 patients infected

By the time authorities caught up with him this spring, Kwiatkowski, 32, had allegedly infected 30 patients with his strain of hepatitis C virus, and "recklessly put patients at risk of death or serious bodily injury," according to the affidavit.

Now, many of those 11 other hospitals that employed him from 2007 on—from Wayne, MI and Poughkeepsie, NY to Johns Hopkins Hospital in Baltimore—are digging in their files to see if they have negative drug screen tests for Kwiatkowski during his employment. Some say they are in the clear. But many others are busy searching for former patients to bring them back for testing.

Kwiatkowski and his checkerboard career managed to elude human resources departments, despite the fact he was reportedly fired from Arizona Heart Hospital in Phoenix after being found unconscious in the men's bathroom next to a toilet containing a syringe labeled fentanyl.  Admitted for care, he tested positive for cocaine and marijuana.

He reportedly relinquished his license and Arizona officials stopped their investigation. The staffing agency that had placed him reported him to the American Registry of Radiologic Technologists, the professional organization that credentialed him. But the registry reportedly said no criminal charges had been filed and that he passed a drug screen. Besides, the registry reportedly said, it "did not have firsthand evidence."

So Kwiatkowski  moved on to Temple University Hospital in Philadelphia. Then to Hays Medical Center in Kansas, which is trying to find 460 patients with whom he may have had contact. Then he went to Houston Medical Center in Warner Robins, GA, which is also trying to notify patients that might have been exposed.

Kwiatkowski was in Pennsylvania previously during 2008 as a technician at UPMC in Pittsburgh. He was fired  there, too, after he was seen in an unauthorized area.

Montero says he must choose words carefully because the case is still under investigation.  But it's clear the matter keeps him awake at night.

"We just don't know"

Healthcare organizations, Montero says, talk about the Exeter saga as if it is unique, he says, "but we just don't know. We need a better system that keeps track of qualifications, sanctions, and processes for healthcare professionals in general, not just about doctors and nurses."

Montero pauses briefly to apologize again. "I'm sorry, I am preaching and I am on my soapbox again. But I am so upset about this. It shouldn't have happened.  Ever."

According to Martin Kramer, spokesman for the federal National Practitioner Data Bank, hospitals are required to report adverse events taken against the clinical privileges of physicians and dentists. Technologists are not granted clinical privileges; they are employed.

Kramer adds that state licensing boards must report adverse actions taken against a practitioner's license, not just physicians and dentists.

But it remains unclear whether Kwiatkowski was required to have a license in the states where he practiced, and even if he did, whether anybody reported his behavior or checked.

Drug addicts are patients, too

Montero points out that another vexing issue is that drug addiction itself is a disease and those who suffer from it are patients, too. "You try to reach a balance between helping someone with a disease and protecting the public. It's extremely tricky, and I'm not sure I have the answer.

"When something like this goes on your record, it never goes away, and people will think you're a drug user all your life. People do make mistakes, but how much should we accept or tolerate?"

Maybe, he says, if such incidents are always reported to a registry as he suggests under a strong national policy, a person could return to work "if they can prove they had treatment and are no longer users."

Not the first case

Clearly better policies are needed because similar cases have popped up around the country. In Colorado, a 26-year old surgical technician injected herself with fentanyl three years ago, and then replaced it with saline for reuse in patients. At least 36 patients were infected with hepatitis C, and hospitals had to find 5,700 patients with whom she could have exposed.

Several weeks ago I asked Montero if he thought Exeter Hospital's small, 100-bed size and rural setting led to the discovery of the problem that eluded those in more urban settings. He didn't think so.

But this week, he's changed his thinking. "In New Hampshire we were able to stop this national problem because of the confluence of several things. First, we had a clinician who thought about it when he saw these infected patients with no risk factors whatsoever. And second, we (the health department) had a good relationship with the hospital and were immediately notified."

At a bigger hospital in a bigger state, patients may not be seen by the same providers, so no one draws the link, "no one talks to each other," Montero says. That's a scary thought.

Montero hopes that the painful episode may teach the nation's hospitals and policymakers an important lesson.

"There's a need for systemic improvements, not just a patchy remedy that we do state-by-state and hospital-by-hospital," he says. "Healthcare is a system and we need to work with it as a system."

"But there I go on the soapbox, preaching again."

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