Hershey Med reports same infection seen in York Hospital patients


Penn State Milton S. Hershey Medical Center has identified a similar bacterial infection outbreak to the one recently announced at WellSpan's York Hospital, according to a Hershey Medical news release.

The medical center is notifying approximately 2,300 patients who underwent open-heart surgery between Nov. 5, 2011, and Nov. 5, 2015, of a possible exposure to nontuberculous mycobacteria, or NTM, in relation to heater-cooler devices used during surgeries. The center replaced its devices on Sunday after identifying three patients with the infection, two of whom died, according to the release.

On Oct. 26, WellSpan sent letters to 1,300 patients who had open-heart surgery at York Hospital after a joint investigation with the state Department of Health and Centers for Disease Control revealed a probable connection between the hospitals heater-cooler devices and eight infected patients, four of whom died.

In July, Hershey Medical infectious disease specialists made a connection with three of its patients who had surgeries at York Hospital with the NTM infection and alerted WellSpan officials, according to the release. These are separate patients to the ones infected at Hershey.

That alert helped prompt WellSpan's initial investigation, and the hospital immediately replaced its heater-cooler devices on orders from the state Department of Health.

Hershey Medical officials have been in contact with WellSpan and the Department of Health since that time and began immediately investigating its own open-heart patients, according to Dr. Carol Freer, the center's chief medical officer.

WellSpan spokesman Brett Marcy said Hershey Medical is one of several hospitals the company has been in contact with since it announced the York Hospital infection outbreak.

"We're committed to being as transparent as possible with other health care facilities," Marcy said. "Anything we learn can be helpful."

Both facilities' devices were manufactured by Sorin Group, which Freer said owns about 85 percent of the market share on the devices in the United States. Hershey Medical replaced its six devices with some manufactured by Sorin and some from another manufacturer, Freer said.

York Hospital replaced its four devices with the same Sorin device, Marcy said, but the hospital is now following the manufacturer's enhanced maintenance protocols, which were sent this June.

Freer said she believed Hershey Medical and York Hospital were the only two hospitals in the state to contact the Department of Health regarding this outbreak, but she feels confident the issue isn't only relevant to those two facilities.

The state's health department sent out its own news release Monday urging health care providers to "increase vigilance" in cleaning and monitoring these devices. No one from the department responded to request for comment.

The department required York Hospital to replace its devices in July, before the investigation determined that the hospital's devices cultured the slow-growing bacteria. The department didn't require Hershey Medical to replace its devices until this past Thursday.

Freer did not know why the department waited to force Hershey Medical to replace its devices, but she noted that the no positive bacterial cultures have been identified on their devices since testing began in early August.

York Hospital admittedly did not follow manufacturer guidelines in cleaning its devices. Hershey Medical has been properly cleaning its devices since testing on them began in August, but Freer did not know whether manufacturer guidelines were being properly followed before that point, she said.

Freer said cleaning equipment used during surgeries is "pretty labor intensive," but that it needs to be taken seriously.

The CDC and U.S. Food and Drug Administration each issued alerts about a potential connection between the devices and infections in mid-October.

The medical center can't confirm its infection cases are related to the devices, according to the release.

—Reach David Weissman at dweissman@yorkdispatch.com.