Chemical Stress Test Issue

Broward Health Medical Center Patient Notice Update

In October 2009, Broward Health Medical Center (BHMC) reviewed one nurse’s practice of reusing single-use supplies when administering intravenous fluids during adult cardiac chemical (pharmacological) stress tests. The review was initiated when a caller to our Compliance Hot Line reported seeing the nurse use the same saline bag and a portion of tubing more than once. Administrators suspended the nurse pending the outcome of a full investigation and the nurse subsequently resigned. She was reported to the Florida Board of Nursing and local authorities.

A detailed internal review was done to determine if patients who received the chemical stress tests may have been put at any risk of exposure to blood borne infection. Patients who received pharmacological stress tests administered by the nurse were sent a notification via certified mail and were encouraged to schedule a screening. Thus far we have not found any likely transmission of blood borne pathogens.

Patients who underwent regular stress tests, which are typically done on a treadmill with electrodes attached to the body, were not at risk.

This was an unacceptable action that once discovered was immediately corrected. We understand that this was alarming but want to assure our patients, employees, physician and the community that we engaged in every way possible to research and alleviate this situation. We consulted with expert physicians and a team of epidemiology and infection experts from the Centers for Disease Control and Prevention (CDC), the Florida Department of Health and the Broward County Health Department.

BHMC took an extremely proactive approach by alerting the local medical and patient community about the situation. We also worked with the media to get the word out to educate the community on this situation.

BHMC’s RESPONSE ACTIONS included:

• Evaluated registered and licensed staff in the stress lab for adherence to infection control and intravenous therapy policies and compliance was validated
• Initiated opening all intravenous administration sets in presence of the patient.
• Conducted an assessment of all outpatient procedural areas of intravenous therapy for compliance with infection control practices. Compliance was validated.
• Re-educated staff on basic sterile procedures and continue to monitor for compliance.
• Thus far we have not found any likely transmission of blood borne pathogens.