Minnesota Department of Health Releases Analysis of St. Cloud Hospital Bloodstream Infection Outbreak


The Minnesota Department of Health (MDH) has released a final report about its investigation into an outbreak of bloodstream infections at St. Cloud Hospital in 2011 that was associated with a healthcare worker diverting narcotics from intravenous (IV) bags.
On Feb. 21, 2011, St. Cloud Hospital notified the health department of a cluster of unusual bacterial bloodstream 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 healthcare 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 healthcare 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 two 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," says commissioner of health Ed Ehlinger, MD. "Healthcare 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 healthcare worker drug diversion elsewhere in the country illustrate how serious drug diversion by healthcare 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 healthcare stakeholders to form a collaborative group to address the issues surrounding healthcare 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, healthcare facilities should review the coalitions resources and put in place the recommendations to reduce the risk of similar diversion episodes in the future," Ehlinger says.


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