This makes for interesting reading.

Mary Rutan Hospital Receives Update on Test Results

Background
On the evening of Thursday, May 21, two pregnant patients delivered healthy babies at Mary Rutan Hospital. Prior to their deliveries, each woman — in a separate room — received a bedside intrathecal injection, a spinal anesthesia given to women in active labor. The anesthesiologist conducting the procedure did not wear a mask as it has historically been normal for anesthesiologists at many hospitals throughout the country not to wear masks during bedside spinal anesthesia procedures.

On Friday, May 22, the patients began to show some signs of illness that may be typical of the spinal anesthesia. When it became apparent that their conditions were worsening, the hospital acted quickly, initiating therapy and transferring both women to its intensive care unit and then to Riverside Methodist Hospital in Columbus. On the following day, it was confirmed that the patients had developed bacterial meningitis. Sadly, one of the patients passed away later that night.

Mary Rutan Hospitalbegan an internal investigation immediately after determining that the two patients had contracted bacterial meningitis, and contacted the Centers for Disease Control and Prevention for guidance in its investigation. Mary Rutan Hospital has been working closely with the CDC, the Ohio Department of Health and the Logan County Health District to determine the cause.

The CDC directed the hospital to provide it with the blood cultures from each of the two patients, the medication that was used in the procedures, and several unopened medications from the same lot numbers. In addition, the CDC directed the hospital to provide five different respiratory samples from the anesthesiologist only, as he was the only individual common to both women during the bedside anesthesia procedures.

Findings
Mary Rutan Hospital and the Ohio Department of Health have received information from the CDC relating to its investigation of the two bacterial meningitis cases. The CDC reports its tests reveal that the bacteria involved in both cases was Streptococcus salivarius, a bacteria commonly found in the mouths of the general population. This confirms tests completed independently by Mary Rutan Hospital, the Mayo Clinic and Riverside Methodist Hospital. The CDC was then able to confirm, through highly specialized DNA testing processes, that the bacteria found in each patient was identical.

The CDC also reported that no Streptococcus salivarius bacteria was found in the medications, ruling that out as a source of the infection. The CDC has determined that two of the respiratory samples taken from the anesthesiologist show bacteria from the same biological group found in each of the two patients.

Conclusion
Although more test results may be available in the future, based on current discussions with the ODH, these findings indicate that it is likely that the anesthesiologist was the source of the bacteria, as he was the only individual common to both women during the bedside anesthesia procedures. In addition, it is probable that the transmission of the bacteria occurred in the course of normal respiratory activity such as breathing and speaking, as the investigation has determined that nothing unusual (coughing, sneezing, etc.) occurred during the administration of the spinal anesthesia.


What is Mary Rutan Hospital doing to uphold safety in the birth center and throughout the hospital?
Patient care and safety is our top priority. Even though our infection rate is well below the national threshold, we are aggressively reviewing all of our infection control procedures and practices throughout the hospital, and have added additional layers of protection for our patients. In regards to the birth center, it is now mandatory for all persons within two arms lengths of a patient receiving a bedside anesthesia procedure to wear a mask. In addition, Mary Rutan Hospital has suspended intrathecal injections indefinitely until further review. The hospital is safe and we will continue to have a safe environment for all of our patients and our community.

Should the anesthesiologist have worn a mask during the procedure?
It has historically been normal for many physicians throughout the country not to wear masks during spinal procedures, which are done bedside and not in the operating room. Many hospitals do not have specific standards in place for the requirement of masks during these procedures and there is not a clear nationwide “standard of care” in this area.

We have issued a policy to the medical staff regarding the use of masks and all of our physicians and anyone within two arms lengths of a patient are now wearing masks at bedside spinal procedures.

Will the anesthesiologist continue to practice at Mary Rutan Hospital?
The anesthesiologist has voluntarily stepped aside during this investigation. The Medical Staff and Board, with input from outside sources, must evaluate the current belief that the anesthesiologist was working within the standard of care for bedside spinal procedures. He will not provide services until this analysis has been completed.

What is Mary Rutan Hospital doing to increase awareness within the medical community?
While this type of bacteria is commonly found in the mouths of the general population, it is extremely rare to contract bacterial meningitis through spinal anesthesia. Because of the rare occurrence of this type of meningitis, a standard has not been established by the medical profession and practices vary widely. Mary Rutan Hospital has been in contact with several hospitals regarding the lack of clear standards in this area, and will be participating in a task force to establish standards for the administration of bedside spinal anesthesia, which hopefully will be used throughout the region.