State investigation finds flaws in hospital routines

Casey Grove

A state investigative team looking into an outbreak this spring of drug- resistant bacteria among the most at-risk babies at Providence Alaska Medical Center found, in some instances, that staff did not wash their hands or wear their medical gowns properly, according to state epidemiologists.

In April, Providence asked state health officials for help with an outbreak of methicillin-resistant Staphylococcus aureus -- known as MRSA -- in the hospital's newborn intensive care unit, where infants, many of them born premature, receive specialized medical care.

Mild infections were detected in 14 infants, the last of which was identified in mid-May, according to Wednesday's edition of the state's Epidemiology Bulletin. Another 34 babies were ultimately found to be carrying the bacteria but showed no signs of infection, the bulletin says.

Observations of staff in the Providence newborn intensive care unit after the outbreak showed incorrect hand-washing and gown-wearing about 31 percent of the time, according to the bulletin.

Though imperfect, the results are typical for intensive care units in the United States, said state epidemiology expert Kim Porter. Medical staff on the units deal with high-stakes situations in a complicated workplace, Porter said.

"It's not a calm, perfectly controlled environment all the time, where you can always do the exact right thing," Porter said. "Sometimes you've got to prioritize providing care to the infant."

While normal bacterial infections can seriously impact a person's health, in the worst cases causing death, the infections are usually treatable with antibiotics. But MRSA presents a unique challenge, because commonly used drugs -- the related methicillin, penicillin and amoxicillin -- are ineffective, according to the Centers for Disease Control.

Providence sees 10 to 12 cases of MRSA a year, but the spring outbreak was the first for the newborn intensive care unit, hospital officials said.

The bacteria found in April was highly resistant to most antibiotics, but it was susceptible to one specific antibiotic and did not prove to be particularly powerful, said Dr. Lily Lou, medical director of the Providence newborn intensive care unit.

"It was very easily treatable," Lou said.

There were no deaths or lasting health impacts to the babies, Lou said. Still, the outbreak was cause for serious concern. Hospital staff at all levels were involved in the response, she said.

"We do not know how this got into the (unit)," Lou said. "But it's carried by people, so it either came from a health-care worker, or a mother or a visitor who was colonized."

And they'll likely never know how the bacteria was introduced, Porter said.

"In situations like this, because the environment is so hard to control, and because it is so easily spread, it's very unlikely that anyone would identify the smoking gun, the one step in the process that allowed transmission to occur," Porter said.

As Providence tested the outbreak bacteria to see what they were dealing with, they isolated infants carrying the strain to a separate room, Lou said. The staff also began using gloves and gowns for all of the unit's patients and received tests themselves, she said. Of the 165 health-care workers caring for the infants, 139 were sampled, and the samples cultured to check for the bacteria, the bulletin says.

"We feel like we cultured a significant amount of our staff, and we didn't find any of the outbreak strain of MRSA in any of those cultures," Lou said.

But in about 20 hours of observation -- the health care workers knew they were being watched -- the team noted some problems common to intensive care units around the country, Porter said.

"What we found was not unexpected," Porter said.

Of the total 196 observations, the staff members did not meet established guidelines for washing hands 32 times and did not meet guidelines for wearing gowns four times, the bulletin says. In 24 observations, staff did not meet guidelines for both hand-washing and gown-wearing. And spacing of infants in the unit was "substantially less than the recommended standard," according to the bulletin.

In a typical example from the observations, a staff member working with a baby carrying the bacteria washed hands and donned gloves, but did not wash hands after removing the gloves, Porter said.

"The hand hygiene and infection control practices are imperfect, but they're actually better than what you see in similar facilities, if you look at the (medical research) literature," Porter said.

Staff in intensive care units tend to follow guidelines between 40 and 70 percent of the time, Porter said.

The state epidemiologists recommended regular observation of the staff members' hand-washing, proper spacing of infants, and continued testing of the infants in the unit, Porter said.

"That means that all kiddos on the unit, once a week, are screened with a swab, that's the kind of Q-Tip-up-the-nose approach, and they have been doing that every week," Porter said.

Though the bacteria has shown up on infants as recently as October, there have been no new infections, and workers stopped using gloves and gowns for all patients at all times, Lou said.

"Gowns and gloves do have an expense, and if they made a difference we would certainly be willing to cover that expense. It's an order of magnitude more important to wash your hands," Lou said.

It's normal to still see signs of the bacteria as long as there are no new infections, Lou said.

The outbreak was a learning experience, Lou said.

"One is how we work together as a team in response to something like this, and another is we've tightened up all of our infection control practices," Lou said. "Our infection risk is probably lower now than it was last year when we weren't even thinking about this."

Reach Casey Grove at or 257-4589.

Anchorage Daily News