- On April 8, 2012, the Arizona Department of Health Services was notified of a patient with acute mediastinitis with blood and pleural fluid cultures positive for MRSA. The report indicated this patient and two other patients with culture-confirmed invasive MRSA infections had undergone procedures recently at an outpatient pain management clinic.
- Investigations by the county and state health departments confirmed that the three MRSA-infected patients received pain injections on the same day, along with 25 other patients. Two MRSA-infected patients received epidural steroid injections, and one received a stellate ganglion block. Ten persons, including the MRSA-infected patients, received contrast injections for radiologic imaging to guide medication needle placement.
- Each morning, clinic staff members typically prepared contrast medium in the patient procedure room, before the arrival of patients; two new syringes were used to withdraw 5 mL each from a 10 mL SDV of contrast medium (300 mgl/mL) and a 10 mL SDV of saline solution. The contents from each syringe then were transferred to the alternate vial, resulting in two 10 mL vials of diluted contrast solution, one for use in the morning and one reserved for the afternoon. Among patients receiving contrast on the day of the outbreak, six received injections from the morning vial and four from the afternoon vial. All of the patients with MRSA infections received diluted contrast from the afternoon vial.
- The three patients with MRSA infections went to a local hospital 4–8 days after their outpatient pain remediation procedures. They required inpatient care for severe infections, including acute mediastinitis, bacterial meningitis, epidural abscess, and sepsis. Hospitalization ranged from 9 to 41 days, with additional long-term acute care required for one patient. The fourth recipient of diluted contrast from the afternoon vial was found deceased at home, 6 days after treatment at the clinic. The cause of death was reported as multiple-drug overdose; however, invasive MRSA infection could not be ruled out,
The nature and purpose of the Partnership in Prevention Award is to highlight and promote the work of one hospital that has achieved sustainable improvements based on the concepts of the “National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination” and is helping to achieve the goals outlined of the HHS Partnership for Patients. Preventing healthcare-associated infections (HAIs) requires a multi-disciplinary and team-based approach – involving facility-level executive leaders, clinical leaders, infection control and prevention experts, and others.
The award program intends to recognize prevention leaders in the U.S. acute care community who have achieved wide-scale reduction and progress toward elimination of targeted HAIs. It also intends to showcase the outstanding efforts of clinicians, hospital executives, and hospital facilities who have improved clinical practice through utilization of evidence-based guidelines, achieved and maintained superior prevention results, and advanced best practices to improve patient safety. Awards will be granted according to specific criteria tied to national standards. The inaugural award will be presented during International Infection Prevention Week, October 15, 2012.