An unexpected increase in catheter-associated bloodstream infections at a children's hospital following introduction of the Spiros closed male connector

James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
American journal of infection control (Impact Factor: 2.21). 07/2011; 40(1):48-50. DOI: 10.1016/j.ajic.2011.02.015
Source: PubMed


Catheter-associated bloodstream infections (CA-BSIs) are associated with increased morbidity and mortality. Previous investigations have reported outbreaks of CA-BSI temporally associated with the use of needleless connector valves or similar devices.
We observed an unexpected increase in the rate of CA-BSI at our institution during August 2009. We used statistical process control and quality improvement methodology to identify the factor(s) associated with this increased rate of CA-BSI.
We reviewed the overall hospital Shewhart U chart for CA-BSI, which indicated special cause variation with an unexpected cluster (6/9; 67%) of CA-BSIs localized to the oncology ward and the bone marrow transplant unit. An event-cause analysis review showed that 5 of these 9 infections were caused by Staphylococcus aureus. We discovered that the Spiros Closed Male Connector (ICU Medical, San Clemente, CA) had been introduced in these 2 units around the same time as the cluster of infections occurred. Based on this information, we discontinued the use of this device, and the CA-BSI rate and distribution of causative microorganisms returned to previous baseline values.
This case study highlights the utility of statistical process control in the surveillance and investigation of CA-BSI.

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