Description of Event or Problem · 1
(B) (6) HOSP MED CTR HAS BEEN INVOLVED WITH A MULTICENTER QUALITY IMPROVEMENT COLLABORATIVE TO REDUCE THE INCIDENCE OF CATHETER-ASSOCIATED BLOODSTREAM INFECTIONS CA-BSI IN CRITICALLY ILL CHILDREN. WE SUCCESSFULLY DECREASED THE INCIDENCE OF CA-BSI IN THIS PARTICULAR POPULATION, AND HAVE SUBSEQUENTLY EXTENDED OUR EXPERIENCE TO THE REST OF OUR HOSP. OUR INFECTION CONTROL DEPT CLOSELY MONITORS AND ALERTS OUR TEAM TO POTENTIAL CA-BSI CASES, WHICH ARE THEN DIAGNOSED ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION GUIDELINES. OUR HOSP HAS REDUCED THE RATE OF CA-BSI TO APPROX 3-4 INFECTIONS PER MONTH. HOWEVER, IN (B) (6) 2009, WE NOTICED AN UNUSUAL AND DRAMATIC INCREASE IN THE NUMBER OF CA-BSI. THERE WERE 9 CA-BSI CASES IN (B) (6), APPROXIMATELY DOUBLE OUR NORMAL RATE. WE REVIEWED THESE CASES CLOSELY AND NOTED THAT 6 OF THE 9 CASES OCCURRED IN OUR HEMATOLOGY/ONCOLOGY/BONE MARROW TRANSPLANT POPULATION. WE ALSO NOTED AN UNUSUAL INCREASE IN THE INCIDENCE OF CA-BSI SECONDARY TO (B) (6) 5 OF THE 9 CASES. MORE IMPORTANTLY, THERE WAS AN UNUSUAL INCREASE IN (B) (6)-RELATED CA-BSI IN THE HEM/ONC/BMT POPULATION - HISTORICALLY, MOST OF THE CA-BSI IN THIS GROUP HAS BEEN DUE TO GRAM NEGATIVE ENTERIC ORGANISMS. WHEN WE REVIEWED THESE CASES FURTHER, WE DISCOVERED A TEMPORAL ASSOCIATION WITH THE TRIAL USE OF THE SPIROS CLOSED MALE CONNECTOR SYSTEM FOR DELIVERY OF CHEMOTHERAPY DRUGS. THIS TRIAL WAS INITIATED BY OUR PHARMACY ON (B) (6) 2009 AND WAS DISCONTINUED ON (B) (6) 2009, DUE TO SEVERAL REPORTS OF CHEMOTHERAPY LEAKS. FOUR OF THE FIVE HEM/ONC/BMT PTS WITH CA-BSI HAD BEEN EXPOSED TO THIS DEVICE. WE DISCONTINUED THE TRIAL AND OUR CA-BSI RATE HAS RETURNED BACK TO ITS BASELINE THE NEXT MONTH AND HAS REMAINED AT THAT BASELINE. DATES OF USE: (B) (6) 2009. DIAGNOSIS: PREVENT CHEMOTHERAPY LEAKAGE WITH USE OF CENTRAL LINE. EVENT ABATED AFTER USE STOPPED: YES.