NEW JERSEY — Hospitals and other healthcare facilities are supposed be where we go to feel better, not worse. Unfortunately, an in-depth investigation into a New Jersey healthcare outpatient facility following an outbreak of septic arthritis in 2017 revealed a number of troubling safety violations. Investigators uncovered inadequate hand hygiene, unsafe injection protocols, and ineffective cleaning and disinfection processes.
Doctors say their study sheds light on just how dangerous healthcare facilities can become when proper sanitary standards and protocols are ignored.
In total, 41 patients who already had osteoarthritis contracted a painful septic arthritis infection after receiving injections in their knee joints. Of those infected, 33 required surgery to remove damaged tissue. These infections cost over $5 million in Medicare claims alone.
“This large, costly outbreak highlights the serious consequences that can occur when healthcare providers do not follow infection prevention recommendations,” comments Kathleen Ross, an epidemiologist with the New Jersey Department of Health, in a statement.
The first red flags appeared in March 2017, when three septic infections were reported at local hospitals and multiple complaints were filed against the facility in question. The facility voluntarily agreed to stop performing procedures while investigators looked into the complaints.
Besides just collecting medical records and data, investigators from both state and county health departments conducted an unannounced inspection on the facility. While on site, health officials interviewed staff, evaluated medical waste handling, and even had the staff perform mock procedures.
The investigators’ discoveries were troubling, to say the least. Violations included a lack of hand-washing stations in exam rooms, exposed syringes, syringes pre-filled up to four days in advance, and generally unsafe handling of single-use and multi-use vials.
Exam tables are supposed to be washed following each and every injection, but investigators say tables at the facility were being cleaned “at most” once a day.
The facility has since re-opened, after undergoing extensive policy changes as recommended by the CDC and other health safety organizations. No additional infection cases have been reported since the facility re-opened its doors.
Investigators say it is imperative that all healthcare facilities make cleanliness and infection prevention a priority. Staff should constantly be reminded of safety rules, and implementing some type of supervision to ensure compliance is recommended.
“Outbreaks related to unsafe injection practices indicate that certain healthcare personnel are either unaware, do not understand, or do not adhere to basic principles of infection prevention and aseptic techniques, confirming a need for education and thorough implementation of infection prevention recommendations,” Ross says.