HENRICO COUNTY, Va. — An outbreak of the antibiotic-resistant infection MRSA circulated in the Neonatal Intensive Care Unit (NICU) at Henrico Doctors’ Hospital for more than three years and infected 94 babies, according to what staff members at the hospital shared with state inspectors.
Inspectors with the Virginia Department of Health's (VDH) Office of Licensure and Certification found during a survey completed January 24 that the hospital failed to consistently implement methods to prevent and control the transmission of infections within the hospital.
MRSA is a frequent source of infections affecting premature and critically ill infants in NICUs, according to the National Institutes of Health, and it can cause a variety of serious infections in NICU babies, which can lead to prolonged hospitalizations and potential long-term medical problems.
A staff member at the hospital told the state on January 23 that the hospital had “not determined the cause” of the outbreak, and the last positive MRSA result was on November 4, 2024.
We asked VDH if any of the babies who contracted MRSA died from it, and we are waiting to hear back.
An infectious disease doctor at a Virginia hospital elsewhere in the state who asked to remain anonymous said they typically see five, maybe 10, MRSA cases a year in the NICU, which is far less than 94 over three years.
The doctor said they felt the CEO of the hospital should have shut down the NICU for a period of time and completely disinfected it.
Helen Haskell, who is on the leadership committee for the non-profit Patient Safety Action Network, called the number of MRSA infections in the NICU “excessive."
“I think it’s a shocking number of infections, and I think it shows a very poor culture of infection control,” Haskell said.
During the inspection, the state watched staff enter the room of a NICU patient with MRSA who had been exposed to another infection called RSV.
A staff member told inspectors all staff and visitors should wear a gown, mask, and gloves when entering that patient’s room, but inspectors watched a staff member enter the infant’s room wearing no personal protective equipment.
That employee, according to the survey, then left the room without performing hand hygiene and entered another infant’s room.
Inside the MRSA-infected baby’s room, inspectors noted a trash can overflowing with trash and soiled gowns hanging over the side of the trash can and on the floor.
When CBS 6 shared those details with the doctor we spoke with, they said "holy cow," and in no circumstance should gowns come in contact with anything in the room besides the trash can because the gowns are contaminated.
"MRSA and other infections are controlled by process. You have to have adequate staffing, you have to have well-trained staff, and you have to have attention to infection control process and to environmental services and environmental cleaning,” Haskell said.
The state found Henrico Doctors’ Hospital:
- Failed to implement a hospital-wide program for surveillance, prevention and control of hospital-associated infections;
- Failed to employ methods to prevent transmission and control of the spread of infections;
- Failed to monitor and track infection prevention or implement strategies to mitigate the MRSA outbreak in the NICU;
- and failed to implement a consistent method of hand hygiene.
HDH is at the center of an investigation into NICU babies with broken bones, and though much of the 97-page report from VDH focuses on failures identified in relation to those incidents, it also addresses the MRSA outbreak.
Watch: State finds Henrico NICU 'failed to protect patients from abuse'
CBS 6 first received a tip about a potential MRSA outbreak at HDH in late January and asked the state about it.
At that time, VDH spokeswoman Maria Reppas said VDH was declining to release any information on the outbreak based on a state code that said VDH is required to preserve the anonymity of patients and practitioners whose medical records are examined during the course of a disease investigation.
“Do you think the public deserves to know about outbreaks like this?” CBS6 investigative reporter Melissa Hipolit asked Helen Haskell with the Patient Safety Action Network.
“Yes,” she replied. “Until you have everybody knowing what is going on, there is simply too much of an incentive to let it go, get used to it.”
In its Plan of Correction, Henrico Doctors’ Hospital, which is owned by HCA, said in February a multidisciplinary team created a scorecard to monitor all actions taken to reduce the spread of MRSA in the NICU.
They stated this plan effectively tracks all infection prevention activities, implementation strategies, and progress toward improvements.
It includes hand hygiene non-compliance being immediately addressed.
The hospital said that during a 12-week surveillance period by VDH, which ended on February 22 of this year, there were no hospital acquired MRSA cases in the NICU.
We requested an interview with someone from HCA about the outbreak, but spokesman Wes Hester said, “We do not have anyone available for interviews at this time and have nothing to add beyond the statement we shared last week.”
CBS 6 is committed to sharing community voices on this important topic. Email your thoughts to the CBS 6 Newsroom.
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