Five patients at Cedars-Sinai Medical Center were unwittingly infected during valve replacement surgeries earlier this year because of tiny tears in a heart surgeon’s latex gloves, hospital officials said.
The infections occurred after microscopic rips in the surgical gloves allowed bacteria from a skin inflammation on the surgeon’s hand to pass into the patients’ hearts, according to the Los Angeles Times (http://lat.ms/ULv1Wv). Four of the patients needed a second operation and are still recovering.
The outbreak in June led to investigations by the hospital and both the Los Angeles County and state departments of public health, the newspaper said. The federal Centers for Disease Control and Prevention was also consulted.
The surgeon, whose name was not released, was not allowed to operate again until he healed. He is still a member of the medical staff but no longer performs surgeries.
Hospital officials told the Times it was a “very unusual occurrence” probably caused by an unfortunate confluence of events: the nature of the surgery, the microscopic rips in the gloves and the surgeon’s skin condition. Valve replacement requires the surgeon to use thick sutures and tie more than 100 knots, which can cause extra stress on the gloves, they said.
Health care-acquired infections cause 99,000 deaths in the country every year, including about 12,000 in California, according to the Times.
Hospitals in the state are required to report certain infections to the California Department of Public Health.
That reporting makes the public more aware of the quality of care provided at hospitals and is an important tool for reducing infections, said Debby Rogers, deputy director of the department’s Center for Health Care Quality.
Cedars-Sinai Medical Center conducts about 360 valve replacement surgeries each year. It said infections occur in fewer than one percent of its cases–lower than the national average.
Harry Sax, vice chairman of the Cedars-Sinai department of surgery, said the hospital’s goal is zero infections.
“Any hospital-acquired infection is unacceptable,” he said.