Awhile back, our epidemiology and licensing team of disease detectives including Jason Lempp, Cara Christ, Vinita Oberoi, Jessica Rigler, Ken Komatsu, Kathy McCanna, Connie Belden, Ken Komatsu, and Shoana Anderson learned of a severe case of a Methicillin-resistant Staphylococcus aureus (MRSA) through our 24-hour disease reporting system. Our team quickly contacted the county public health department which immediately began an investigation into the cause.
Their investigation quickly uncovered more people with the infection who had been seen the same day. The detectives also found that a single-dose vial of solution used for pain meds was diluted and used for more than one patient. Medication shortages often push health-care providers to search for solutions to provide comparable care using limited supplies- which is what looks like happened in this case.
Our work with the county led to an improvement in the clinic’s practices through discontinued use of mixed products; appropriate use of single dose vials; using personal protective equipment, such as face masks, during medication preparation and injections procedures; education of all staff on infection control practices; and the development of a plan to report further suspected infections. This Arizona investigation was written up in this week’s CDC Feature Article and has added to the national picture on injection safety best practices.
Note: Health-care-associated infections (HAI) affect nearly 100,000 people every year and result in over $30B in unnecessary health-care costs (HHS). Our HAI Program works with partners across the state to rapidly identify and help prevent these infections. Traditionally, the focus of preventing HAIs has been in hospital settings, but more and more people are being identified outside of hospital settings. They can happen at any health-care facility, but simple steps can help protect patients.