June 15, 2008
Congress of the United States
House of Representatives
Committee on Oversight and Government Reform
2157 Rayburn House Office Building
Washington, DC 20515-6143

Attn: Henry A. Waxman, Chairman

RE: MRSA/Infection Control Practices at Kettering Hospital,
Kettering, Ohio
Dear Congressman Waxman:
In the wake of the catastrophe in Nevada at the Endoscopy Center of
Southern Nevada, I feel, as a nurse I must speak up about the
deplorable infection control practices at Kettering Hospital
(Kettering, Ohio) and affiliated hospitals within the Kettering Health
Network. As a health care professional, family and friends often ask
how the incident in Nevada could have happened, surely the nurses
there knew better. My response is always the same, "It happened
because someone in authority told them to do it". If they didn't do
as they were told, the nurses would have lost their jobs. Far too
often nurses are instructed to perform activities which we know
inherently are wrong; however, the leadership of the organization
mandates it. How very unfortunate for the nurses who were employed at
the Endoscopy Center of Southern Nevada.
Since I first began my employment as a circulating RN in surgery at
Kettering Hospital in 2001, I noticed that infection control practices
were not being followed, especially concerning patients with resistant
infections such as VRE, MRSA and C-Diff. I brought this to the
attention of Kathy Gonce, RN and Greg Carter, RN sometime in 2002. At
that time Kathy was the Nurse Manager of Surgery and Greg was in
charge of Infection Control. The response was something along the
lines of more staff education was needed. I never saw an improvement
in practices.
Things came to a head for me in late October of 2006 when I felt my
personal safety was compromised when Joanne Hamilton, RN, current
Director of Surgery at Kettering Hospital, advised me that I could no
longer wear gloves while transporting surgical patients.
Throughout the remainder of 2006 and into 2007 there was ongoing
discussion and debate concerning infection control practices at
Kettering Hospital. In a December 2006 staff meeting, surgery staff
was informed by the Infection Control Department that we were no
longer permitted to wear gloves in the surgical "outer core". This is
an area of surgery that is off limits to the public. Patients are
transported from the surgical waiting areas to the surgical suites and
then to the recovery room post surgery through this hallway. Surgical
waste (trash bags, linen bags, case carts with dirty instruments) is
also transported from the surgical suites to the decontamination room
through this hallway. When I specifically asked about the dirty trash
bags and linen bags, I was told point blank that gloves were not to be
worn in this hallway even when transporting dirty trash or linen bags.
We were also advised that we could no longer wear gloves or protective
gowns while transporting patients with VRE and MRSA which is in direct
contradiction to the CDC guidelines.
I became fearful for my health and safety and contacted the
Occupational Safety and Health Administration. This began the long
debate over the word "potential". The following is an excerpt from a
letter to Richard T. Gilgrist, CIH, Area Director for OSHA, RE: OSHA
Complaint #206119927

***I am greatly distressed and still can not comprehend how college
educated individuals who have clinical experience do not understand
that the POTENTIAL for exposure exists whenever a health care provider
is in close proximity to a patient as when transporting throughout the
hospital. In a document that I produced dated November 9, 2006 I
produced 20 scenarios that occur every day in the Operating Room that
would potentially expose workers to infectious materials. Further I
noted, "It can be reasonably anticipated that any worker directly in
an OR or transporting a patient to and from the OR may have contact
with blood or OPIM and should; therefore, wear PPE as mandated by
OSHA". The response from Kettering Hospital's representative, Beverly
Morris, RN, MS, totally ignores these statements.

It is ironic that Kettering hired a consultant to help prepare for
the Joint Commission survey when I have requested twice that an
Infection Control consultant be brought in to educate staff (all
hospital staff, not just in the OR) on the correct handling of
patients with multi-resistant organisms. It leaves the impression
that Kettering is not concerned with protecting their patients,
visitors or staff. February 26, 2007***

While a representative from OSHA did visit Kettering Hospital, the
conclusion was that since there are policies in place at Kettering;
nothing further could be done. I supplied numerous incidents to OSHA
when polices were not being followed and strongly implored Mr.
Gilgrist to supply a representative from OSHA to come to a staff
meeting so that the staff who are on the front lines every day can
discuss the issues concerning infection control at Kettering Hospital.
Excerpts from letters to OSHA:

***The OR staff on Wednesdays typically have Inservice training, I
would like to invite OSHA to meet with the staff of the OR as well as
the anesthesia staff to discuss with the workers on the front lines
what their interpretation of "potential" is. You can contact Kathy
Gonce, RN (interim education coordinator) at 937-395-8608 to arrange
this meeting. March 23, 2007***

***I strongly urge a second site visit. Once again, I ask that you
please attend a staff Inservice and speak with the workers who are
exposed daily about what our interpretation of "potential" exposure
is. We additionally need to redefine what the "work" area is for the
Operating Room arena. March 28, 2007***

***Again, I would plead with you to attend a staff Inservice with the
staff from the perioperative area including OR staff, Pre and Post
operative staff, anesthesia care providers and any other hospital
employee that has an interest in protecting themselves from blood or
OPIM. Two issues need to be resolved:

1. Can health care providers in the perioperative setting reasonably
anticipate exposure to blood or other potentially infectious materials?
2. How is the patient care area in the perioperative setting defined?
Is it just the physical operating room itself or does it extend
beyond to the pre and post operative areas as well as the hallways in
which patients, specimens, cultures, blood samples and dirty trash and
linens are transported?

These points should be answered by the clinicians who are experienced
in the area and not by managers with little or no clinical experience,
by JCAHO or any other governing body.




Lastly, in letters from Kettering Hospital to OSHA dated February 7,
and February 15, 2007 it is stated, "We welcome recommendations to
improve the safety of our patients and staff". I have recommended
numerous times to Pam McCartney, RN, the Infection Control Manager to
bring in an Infection Control specialist who has experience and
knowledge of the intricacies of the perioperative setting to provide
training including mock cases with hands on education. This
recommendation has been summarily ignored. April 5, 2007***

I was advised by OSHA that they were too busy and could not supply a
speaker. I advised OSHA that I had not requested a speaker. I had
requested a listener. My request was summarily ignored.

During all of my years as an employee at Kettering Hospital I had
received good performance reviews. It wasn't until I reported the
hospital to OSHA that things began to change. Three transfer requests
were denied. One request was routed to the wrong person. It was
routed to one of the respondents to the OSHA matter with no valid
reason. A written discipline was placed in my record without my
knowledge or signature. When employee awards were given in the spring
of 2007 for years of service, the names of all the recipients were
read by Joanne Hamilton, RN. That is, all except mine. I received an
award for ten years of service to Kettering Hospital and my name was
not announced. When I made a comment, Joanne looked at me directly,
didn't miss a beat and continued on with the list. I was asked to
fraudulently chart the administration of an antibiotic and then
disciplined for refusing to do so.

While employed by Kettering Hospital in Kettering Ohio, as a
circulating RN, I was involved in a case on Wednesday, September 5,
2007. The patient was to have an open heart procedure. The
anesthesia care provider normally administers the preoperative
antibiotic and is responsible for charting the administration of said
antibiotic. I was advised many months prior to this incident by D.
Toadvine, RN who was the nursing educator at the time that I was not
to chart the administration of any medication if I did not administer
it myself.

On Monday, September 10, 2007, a full 5 days later, Jim Benton, RN,
Open Heart Coordinator for Kettering Hospital approached me and
advised me that I needed to "fix" the record for this case. I advised
him that I could not change a record for an antibiotic that I did not
administer nor did I witness being administered. The following day,
Tuesday, September 11, 2007 I placed a phone call to the Ohio Board of
Nursing to get clarification concerning this issue. I left a message
for someone to call.

Two days later on Wednesday, September 12, 2007 I was called into
Joanne Hamilton, RN's (Director of Surgery) office where I was
confronted by her as well as Jim Benton, RN and was again advised that
I need to "correct" the record. I was given a written warning which I
signed stating, "I will not engage in fraudulent criminal activity".
Later that same day I was called into Joanne Hamilton, RN's office
where I was confronted by her as well as Brenda Kuhn, RN, Vice
President of Nursing at Kettering Hospital. I advised them that I
would continue to practice nursing as I had been instructed by D.
Toadvine, RN until I got a definitive answer from the Ohio State Board
of Nursing.

The following day, Thursday, September 13, 2007 I left an urgent
message with the Ohio State Board of Nursing concerning this issue.
Later that same day I received a phone call from Amy Reddick, RN with
the Ohio State Board of Nursing. Amy advised me that I could in fact,
scribe the administration of any medication that I witness, as long as
I did indeed witness it. When I described the scenario where I was
being asked to change a document to chart the administration of an
antibiotic that I did not administer nor did I witness being given,
Amy advised me that I absolutely could not chart that information,
that it would be fraudulent to do so.

I feel nurses at Kettering Hospital are being mandated to chart the
administration of medications that they did not administer nor witness
in order to meet Medicare guidelines for preoperative antibiotic
administration. While I understand the need to meet the guidelines,
it does not benefit anyone to chart the administration of a medication
that may or may not have been given. In fact, I believe it is a very
dangerous practice. The guidelines were established based on research
that indicates better outcomes when followed. Simply charting the
administration does not always indicate that the medication was
actually given. I feel the practices at Kettering Hospital are
fraudulent and put the nurses who work in surgery in jeopardy from a
legal perspective.

On Monday, September 17, 2007 I met with Beverly Morris, RN, Vice
President of Human Resources and Brenda Kuhn, Vice President of
Nursing at Kettering Hospital to discuss several issues related to
infection control and staff discord in the OR at Kettering Hospital.
They are both very aware of the infection control issues as well as
the request for fraudulent documentation. After that meeting I was
called into Joanne Hamilton, RN's office and was told I was being put
on a 48 hour suspension. On Thursday, September 20, 2007, Karen
Gorby, RN with Tim Gillum, RN in attendance, relieved me of my duties
at Kettering Hospital.

Why did the nurses in Nevada reuse syringes when they knew it was
wrong to do so?, to avoid the turmoil I endured at Kettering Hospital
when I tried to do the right thing.

The procedures for handling patients with resistant organisms are
very different, universal precautions are not enough. Time after time
I was exposed to patients with MRSA, VRE and C-Diff and did not find
out until after the fact because communication is so lax at Kettering.
Not only was I exposed wrongfully as an employee, I was also exposed
while a patient in May 2007. On Tuesday, May 29, 2007, I had a
vaginal hysterectomy at Kettering Hospital. After my procedure I had
an IV and a foley catheter until my discharge from the hospital the
following day. That night the nursing assistant on duty came into my
room, did not wash her hands, did not don gloves, emptied my foley
catheter which was full all the way to the to top with urine, recorded
the amount and left the room without washing her hands. Again, I had
a vaginal hysterectomy, I had bleeding in the perineal area for
several days. The following morning I was given a pan of water and a
wash cloth by a different nursing assistant. This nursing assistant
did not wash her hands upon entering the room, did not don gloves when
she took the dirty pan of water from me or when she rung the water out
of the cloth!!! She did wash her hands before she left the room. If
these health care workers handle my body fluids in such an unsafe and
entirely disgusting manner, I have to assume that is how they handle
all of the patient's body fluids. What did they expose me to???? I
know for a fact that there was a patient on the same floor in
isolation as I saw the isolation sign outside the door the evening
before while I was walking in the hallway.

According to the CDC, if you have been hospitalized, within a year of
the hospitalization you are at increased risk for acquiring MRSA. On
Tuesday, April 1, 2008 I woke up with a boil on my perineal area. At
first it looked like a small infected hair but it was painful so I
applied heat. It finally came to a head and I was surprised at the
amount of drainage and realized it was not just a small infected hair
but a full fledged boil. I have never had a boil or any infection with
this amount of drainage in my entire life. While I was busy trying to
care for the boil and keep the drainage contained, I woke up two days
later on Thursday, April 3, 2008 with a "spider bite" on my abdomen
about two inches below my umbilicus, right around the area where my
uterus would have been. I had never had a spider bite but the lesion
looked exactly like the pictures I had seen of spider bites. I was
busy for several more days trying to clear up the boil and didn't pay
too much attention to the "spider bite". As the boil cleared and the
spider bite became more invasive, I realized I needed to do something.
Being an intelligent RN, I searched online and discovered the way to
treat a spider bite is to apply ice. I read that you should never
apply heat to a spider bite as it drives the venom deeper. I was very
diligent at applying ice as I was becoming increasingly sicker and
sicker. I had to miss two days of work at a new job because I was so
sick. I didn't know that spider bites could make a person so sick.
Finally at 1:00 AM on Saturday, April 10, 2008, a full 7 days after I
first discovered the "spider bite", it ruptured and began draining
truly disgusting purulent drainage. How had my "spider bite" become
infected like this?? I called my primary care doctor's office
Saturday afternoon. They were already closed for the day but I spoke
to the doctor on call who urged me to go to an Urgent Care Center
since the area of swelling had already become as large as a softball.
The UCC doctor gave me a prescription for Bactrim. When I went back
to work on Monday, April 12, 2008, I discussed my "spider bite" with a
co-worker who advised me that MRSA skin infections start out looking
like spider bites. I was obviously distraught. I made an appointment
and saw my PCP, Steven Robbe, MD on Wednesday, April 16, 2008. By
that time I had been on antibiotics since Saturday so it would have
been futile to take cultures; however, based on the clinical symptoms,
Dr. Robbe confirmed, that I did indeed have an MRSA infection. This
infection was made all the worse, of course; since I ignored it
thinking it was a spider bite and applied ice which drove the
infection ever deeper.

Mr. Waxman, I can not begin to tell you the full extent of the toll
this situation brought on by the horrendous infection control
practices at Kettering Hospital has caused me. I lost my job trying
to make things right for every person that walks through the doors at
Kettering Hospital; from the patients, their guests and the staff. I
became infected with one of the very organisims I tried so hard to
protect myself from. The cost to me as a result was great. I lost
two days of work. I had to throw away all of the products that were in
my bathroom before I realized that I had an MRSA infection (soap,
shampoos, eye drops, etc). I can no longer wash with ordinary soap.
For the rest of my life I will wash with Hibiclens or some other
antibacterial product. Hibiclens is much more expensive than normal
soap. I also rinse my mouth out daily with Peroxyl just in case I
might be harboring MRSA in my mouth. I treated my nares with
Mupiricin and feel that I need to continually treat myself on a
regular basis. I run my clothes through the wash cycle twice.

The financial costs have been great and will continue for the rest of
my life. The emotional and psychological costs have been devastating.
I have lost friends and have been estranged from family members
because of this infection. I have had to go into therapy for anger
management. I want to go on with my life but know that I will never,
ever be the same.

There are several things I would like to see happen. First, I
strongly feel that some government entity needs to step up to the
plate and do a thorough investigation of Kettering Hospital including
the number of hospital acquired MRSA infections even if it means
advertising to the public since MRSA is not, unfortunately; a
reportable disease in Ohio. The health care staff in all areas of
Kettering Health Network needs to have the opportunity to speak, not
to be spoken to. I recommend that town hall style meetings with staff
only, no management involvement, be conducted so that the true workers
on the front lines can speak without fear of reprisals. Sending a
health care worker into their job without adequate protection is
exactly like sending a soldier or a police officer out into the field
without their guns.

Secondly, I would like to see legislation that requires hospitals to
offer support groups for victims of hospital acquired infections.

Thirdly, much more research and education of the public needs to be
done on MRSA as well as other resistant organisms. There simply isn't
enough known about these diseases by the professionals or the public.

Mr. Waxman, in closing let me state, I would very much like to speak
before Congress the next time there is a discussion concerning
Infectious Diseases, especially; hospital acquired diseases.
Sincerely,

Caryl J. Carver, RN, BSN
8310 Woodgrove Court
Centerville, Ohio 45458
937-361-9850
mrsasucks@...