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Report Finds Poor Communications During VA Legionella Outbreak

A report released Thursday by the American Legion finds that the VA Pittsburgh Health System has responded well to the outbreak of Legionella in 2011 and 2012 that took the lives of at least five veterans. 

However, the report finds the Veterans Administration needs to empower the 152 hospitals in the system to better communicate during a crisis.

Jacob Gadd, American Legion deputy director for healthcare, said that since the outbreak the Pittsburgh VA has formed a water safety committee, which had made important recommendations that have been implemented.

“I would feel safe using this facility,” Gadd said.

The report is tacit on the medical response to the outbreak, but Gadd said the American Legion did learn a great deal during a site visit last year.

“From our understanding there was a lack of documentation on monitoring for periods of time, inconsistent communication, they did a root-cause analysis within the hospital there that found that not everyone understood their roles and responsibility with Legionella,” said Gadd, who notes high staff turnover exasperated the problem.

The report instead focused on communications with the region’s veterans.  During interviews with local vets, the Legion found that most of them learned about the outbreak through the media and then became confused and scared when VA officials refused to comment. 

The report lays much of the blame on the office in Washington.

“The facility had a press release ready to go out to the community to alert them that there was a Legionella problem,” Gadd said. 

That release was not approved by administration in Washington, and it was never released. The Legion has called on the VA to empower the local hospitals to speak up when there are problems. 

“It takes weeks to months to get approval to send these press releases out,” Gadd said. “Washington cannot manage crises and it has to empower local staff … to do their jobs.”

The Veterans Administration has not responded to requests for comment.