This is why it came as quite a surprise to Perl and her team when they were called in to investigate the bloodstream infection cases in the PICU during just such a patient safety exercise to implement best practices for insertion and care of catheters.
According to statistics compiled quarterly by the hospital, bloodstream infections on the unit increased over the latter half of 2004. Infection rates increased from a low in the spring of slightly more than four days for every 1,000 days patients spent with catheters in the ICU, which is the relative norm, to a high of 17.3 days by the end of the summer. Infection rates stayed relatively high to the end of the year, at 11.9 days.
But, according to the infection control team, there was at first no clear "smoking gun" in this investigation. "The staff was already focused on best safety practices and following infection control procedures to the letter," says Maragakis.
By early 2005, analysis of blood specimens from infected patients showed that no single bacterium was responsible and that 26 percent of specimens were polymicrobial, containing more than one kind of bacterium. The norm for these kinds of infections was lower, at 8 percent. Having not found human error as the likely cause of infection, the Hopkins team was left with few remaining possibilities except that the likely source was mechanical.
Indeed, one of the infection control staff, Karen Bradley, R.N., B.S.N., had recently attended a national meeting of hospital colleagues where new catheter valve devices were reported to have caused an outbreak of bloodstream infe
Contact: David March
Johns Hopkins Medical Institutions