CMS: Avoid outbreaks with infection control

Inspectors will observe actions of HCWs

A mid some high-profile outbreaks of hepatitis C, the Center for Medicare & Medicaid Services (CMS) has put health care facilities on notice that inspectors will zero in on infection control practices and observe the practices of health care workers.1

“The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases,” CMS said in a June 2012 memorandum.

CMS will be looking at compliance with cleaning of patient rooms, hand hygiene of health care workers, use of personal protective equipment, medication injection practices, sterilization of critical equipment, high-level disinfection of semi-critical equipment, and appropriate use of patient isolation precautions.

From 2008 to 2011, 31 outbreaks of hepatitis B or C in health care settings led to the infection of about 250 people and the notification of 88,000 for testing. The major culprit: Using single-dose vials on more than one patient.

Some hospitals have reused single-dose vials because of drug shortages. CMS says hospitals can repackage the medication in a sterile environment following USP standards. Medications cannot be repackaged on a patient care unit.

“Our policy is to cite the reuse of SDVs for multiple patients as an infection control deficiency, since this practice of reuse is in conflict with nationally recognized standards,” the memorandum says.

The most egregious case occurred in Nevada where 50,000 patients of the now closed Endoscopy Center of Southern Nevada and 13,000 at a related clinic were notified about possible exposure. Eight acute HCV cases were linked to the clinic and 106 were “possibly linked” to the reuse of single-dose vials, public health authorities said.2 After one of the patients died of HCV this year, a grand jury indicted the owner (a gastroenterologist) and two nurse anesthetists on second-degree murder charges.

The Centers for Disease Control and Prevention also has cautioned health care providers that bloodborne pathogens aren’t the only infectious disease risks linked to reuse of single-dose vials on more than one patient. Improper repackaging or reuse of vials led to invasive Staph aureus infections in 10 patients in Delaware and Arizona after pain injections. Three of the infections were methicillin-resistant.3

The patients were hospitalized with sepsis, bacterial meningitis, and other severe infections.

In the Delaware case, which was in an orthopedic clinic, public health authorities found that two employees who prepared injections were colonized with Staph aureus. One had a strain that matched the outbreak strain.

CDC has launched a campaign to raise awareness about the need to use single-dose vials only on one patient.


1. Center for Medicare & Medicaid Services. Safe Use of Single Dose/Single Use Medications to Prevent Healthcare-associated Infections, June 15, 2012. Available at Accessed on August 22, 2012.

2. Southern Nevada Health District. Outbreak of Hepatitis C at Outpatient Surgical Centers,December 2009. Available at Accessed on August 22, 2012.

3. Centers for Disease Control and Prevention. Invasive Staphylococcus aureus infections associated with pain injections and reuse of single-dose vials — Arizona and Delaware, 2012. MMWR 2012; 61:501-504.