The state health department lost two weeks of investigative time on the now-infamous hepatitis C cases while a third party it won’t name neglected to ship out key viral samples for genetic testing.
The frustrating testing delay in early May is one of many moments when the state health investigation diverged from TV scripts packed with laboratory miracles and scientists carrying arrest warrants.
From late April to late June, different agencies and health offices held isolated facts about the infections and suspect Kristen Diane Parker. But they were blocked by circumstance, lack of communication or privacy laws from sharing key details, while Parker went on to expose patients at another hospital.
Colorado Department of Public Health and Environment investigators needed those May test results from two hepatitis C cases to see if the samples genetically matched each other, meaning they were caused by the same source.
The probe had otherwise stalled in May — the only link identified in the two cases was February surgeries two days apart at Rose Medical Center. There was no inkling a hepatitis C-carrying employee worked there, or that she had breached sterility rules with infected needles.
Hospitals are rarely suspected as infection points for hepatitis C, precisely because of their sterile procedures.
“We waited for May for lab tests we never got, and the lab tests were a key part of our strategy to either look more at Rose or exclude Rose,” said Colorado’s chief medical officer, Ned Calonge.
When the state called the unidentified lab on May 14 to see if results were back yet, investigators learned the samples had never been sent. They were frustrated again on June 1, when the lab finally told them one of those two samples did not have enough viral material to properly test.
Investigation points to Rose
State health officials first contacted Rose about the cases in late April, after discovering that two patients who had surgery at the hospital in a two-day period in February had tested positive for hepatitis C. The state informed Rose of the infections and requested the patients’ records.
It was unusual that the individuals had surgery within days of each other, Calonge said. State case workers call such ties a “temporal and geographic relationship,” which demand further probing.
But the state routinely looks at other potential sources, ranging from other medical incidents to drug use or intimate partners. Colorado receives about 11 new reports of hepatitis C every day.
Rose, in turn, routinely receives requests from the state for records of patients with hepatitis or other reportable illnesses, said Lindy Garvin, Rose vice president of risk management. That doesn’t mean the patient acquired the infection at Rose. The hospital supplied the records and took no further action until early June, she said.
That’s when Rose notified the state a surgical employee — Parker — had been fired in April for stealing painkillers and that she had tested positive for hepatitis C when she was hired in October.
Garvin said Rose made the connection after hearing from state health investigators June 2, who said the only common link in the hepatitis C cases appeared to be a Rose surgery.
But Calonge said he can find no record of such contact, and that it was Rose that contacted the state and first mentioned 26-year-old Parker as a potential link.
“I don’t have anything from the people doing the investigation that that occurred,” Calonge said. “My information was that we reviewed the cases, we were waiting for lab testing and then Rose contacted us.”
Tracing source of infection
Garvin said after hearing from the state on June 2, Rose employees focused on the surgery rooms. First they reviewed records of sterilization checklists and found nothing wrong. A next step was looking at a list of surgery personnel; that, Garvin says, is when Rose human resources and the director of surgery said, “Gosh, we terminated (Parker) for drug diversion.”
Rose pulled her personnel file and found the positive hepatitis C status from Parker’s pre-employment blood screening.
Rose says it called the state back on June 3 with all it knew about Parker. At the state’s suggestion, they scheduled a June 11 meeting to discuss the case. Calonge said the state did not know enough then — including the fact that Parker was then employed at Audubon Surgery Center in Colorado Springs — to prompt quicker action.
Both Rose and the state emphasize they still had no proof the virus came from Parker, or any idea how it was transmitted. Court records show Denver police contacted Parker in late April about the drug diversion, but there was no follow-up meeting with police until the end of June. In April, Parker admitted stealing fentanyl but didn’t say she had contaminated needles.
Through mid-June, Rose provided the state with a roster of surgery patients during some of Parker’s employment. The state cross-checked that with its statewide list of hepatitis cases and found two more cases. The state later widened the search and has now found 11 cases linked to Parker.
After interviewing the two new patients in mid-June, the state was convinced the hepatitis outbreak was related to surgery at Rose. Finding Parker became a top priority.
“We started saying we need to talk to this person, we need to find them and interview them and see if they can provide us additional information,” Calonge said.
State health officials didn’t interview Parker until June 22. Calonge said she was hard to track and did not respond to phone calls or registered letters.
“We can document we were trying very hard to locate this person,” he said.
Asked if the health department could have collaborated with police, Calonge noted state laws are specifically meant to protect the privacy of disease or virus victims, so that stopping outbreaks is the priority.
“We don’t have badges,” Calonge said.
State officials say they are already worried their appearance of coordinating with federal drug prosecution in Parker’s case will have “a chilling effect” on future disease tracking.
Putting the story together
In interviews with state health officials from June 22 to 25, Parker filled in many of the gaps that had perplexed investigators. She detailed stealing full syringes of fentanyl from surgery areas and replacing them with syringes she had filled with similarly clear saline and relabeled as the painkiller.
She had already used some of those needles refilled with saline on herself, thus providing the avenue for infection: Doctors might inject patients using her dirty needles or might use saline from containers contaminated when she refilled the used needles.
Calonge said health officials had the “indication” on June 22 that Parker wouldn’t work at Audubon anymore. On June 23, he said, “that became problematic,” and the state moved to write a public-health order barring her from further work. She did not work June 24 or 25, Calonge said, and the notice came out June 25.
Parker was arrested June 30 on state charges of felony drug possession and fraud. Denver has now ceded the case to federal charges by the U.S. attorney, who may add charges of patient harm.
Frustrations in the aftermath
Rose, meanwhile, was working with state officials and the U.S. Centers for Disease Control and Prevention on how to tell thousands of patients they would need testing.
From mid- to late June, they consulted on how many of the surgery patients really needed testing, what they should be tested for, how to break it to them, and how to set up a call center for a flood of questions.
In those two weeks, Rose says, it was assured by disease officials the delay would not harm the health of any patients who had contracted hepatitis C.
Calonge remains frustrated by the delayed blood results in early May. But he adds quicker results may have had no final bearing on the case — the big break came when Parker confessed her dirty needles in late June. Without her revealing the “mechanism” for infection, the state would have waited weeks or months for genetic matches of Parker’s blood with other patients.
Rose said it had no role in seeking Parker after her April firing. They called her in for a human-resources meeting about the drug diversion, but she never showed up. After that, Rose officials said, state health had the only investigating authority.
Once everyone focused on Parker in June, the public silence was unfortunate but necessary, Rose’s Garvin said.
“Was it an agonizing two weeks?” she said. “Absolutely.”
Michael Booth: 303-954-1686 or mbooth@denverpost.com
Record Unraveled
February 2008: Kristen Parker, above, is fired by Northern Westchester Hospital in New York.
Oct. 8, 2008: Parker is hired by Rose Medical Center as a surgical-scrub technician.
Oct. 21, 2008: Parker starts work.
March 23: A Rose employee reports she was stuck by a needle in Parker’s pocket and that Parker was in a room she was not assigned to. She is suspended pending a drug test.
March 30: The drug test comes back negative for narcotics, and Parker returns to work. Parker later tells investigators she had put fentanyl in her pocket but not yet used it.
April 13: Parker is caught in an operating room where she was not assigned, triggering an immediate suspension and a drug test.
April 21: Results of a drug test are positive for fentanyl. Parker is told to report to human resources. On April 22, she does not show and is sent a certified letter of termination.
April 24: Rose informs the state health department, the U.S. Drug Enforcement Administration and the state Board of Pharmacy about the termination of an employee for cause.
Week of April 27: State health department discovers a second patient with hepatitis C who had surgery at Rose, and asks Rose for records. A Denver police detective interviews Parker about the drug diversion accusation but does not know anything about her hepatitis C status or her swapping dirty needles for clean ones.
Early May: State health department reviews Rose’s records from the two patients.
May 4: Parker begins work at Audubon Surgery Center in Colorado Springs, after Audubon says she passed a drug test and references did not say she’d been fired.
May 14: State officials discover the two patient blood samples had not yet been sent for testing, after a two-week delay. The test might have linked the two patients definitively to each other and therefore, to Rose.
June 2: Rose says it is contacted by the state and told their surgery room is the top possibility for hepatitis C contact. Rose begins review of all surgery-related records, including personnel.
June 3: Rose tells the state a surgery employee— Parker — had been fired for drug use and also had hepatitis C.
June 11: State health department and Rose Medical Center Clinical and Quality representatives meet to discuss potential surgical exposure of the hepatitis C patients.
June 12-29: Rose sends state lists of all surgery patients during Parker’s employment, and state compares names to hepatitis C cases, finding more matches. Rose begins working with state and federal CDC on how to notify and test patients.
Mid-June: State searches for Parker in order to conduct interviews, making calls and sending registered letters.
June 22 to 25: State interviews Parker. She admits stealing fentanyl and for the first time says she put dirty syringes back for use on patients, at both Rose and Audubon.
June 25: State issues public- health order barring Parker from working with patients or drugs.
June 30: Denver police arrest Parker on state charges of drug possession and fraud. Case is later taken over by U.S. attorney, with potential charges of patient harm.
July 2: Rose announces its public-health notice to screen 4,700 former surgical patients for hepatitis C.
July 6: Letters are mailed to all patients needing screening. Parker remains in federal custody after a judge rejects bail.
July 17: State announces a total of 11 Rose patients who now have hepatitis C results with preliminary matches to Parker.
Sources: Rose Medical Center, Colorado Department of Public Health and Environment, affidavit, court records
