October 2, 2012
Health Department releases final analysis of 2011 St. Cloud Hospital blood infection outbreak
Harm identified during investigation prompts new efforts to address drug diversion
The Minnesota Department of Health (MDH) has released a final report about its investigation into an outbreak of blood infections at St Cloud Hospital in 2011 that was associated with a health care worker diverting narcotics from intravenous (IV) bags.
On February 21, 2011, the St. Cloud Hospital notified the health department of a cluster of unusual bacterial blood infections among patients. Ultimately, MDH epidemiologists identified 25 patients that had unusual bacteria in their blood. A common factor was that the affected patients were all in the same post-surgical ward and all had received IV-pain-killing narcotics. The MDH epidemiological investigation with support from experts at the Centers for Disease Control and Prevention pointed to the possibility that a health care worker had inadvertently introduced bacteria into the IV bags while withdrawing narcotics for personal use. This information enabled the hospital to focus on drug diversion as a possible cause of the outbreak. On March 8, the St. Cloud Hospital informed MDH that a health care worker had admitted to diverting narcotics.
Among the 25 patients who had blood infections, six required intensive care, three had unplanned surgeries and one died within 2 days of their blood infection occurring. Some of the adverse consequences in these patients may be linked to inadequate pain management resulting from the diversion.
"This is a tragic case that shows why it is so important for Minnesota to have a team of scientists on hand who can work to protect the health and lives of Minnesotans by quickly investigating unusual clusters of infectious illnesses," said Commissioner of Health Ed Ehlinger, M.D. "Health care workers are not immune to narcotic abuse and sadly, this is a reminder of the possible harm to the public that can result when narcotics are diverted."
This situation and multiple other instances of health care worker drug diversion elsewhere in the country illustrate how serious drug diversion by health care workers can be and the significant impact it can have on patients. In May 2011, MDH and the Minnesota Hospital Association (MHA) invited a coalition of hospital, provider, law enforcement, licensing and other health care stakeholders to form a collaborative group to address the issues surrounding health care worker drug diversion.
The coalition completed its work in April 2012 and issued a final report and a road map of resources for health care facilities to use to enhance their prevention programs of drug diversions. These resources and the epidemiological report can be found at: http://www.health.state.mn.us/patientsafety/drugdiversion/index.html.
"Nothing can undo the harm patients suffered. However, the coalition was an excellent example of government, hospitals and medical professionals working together to address an important problem. And moving forward, health care facilities should review the coalition’s resources and put in place the recommendations to reduce the risk of similar diversion episodes in the future," Ehlinger said.
MDH Infectious Disease Epidemiology, Prevention and Control Division