Bradley found that in April 2004, the Hopkins PICU had, by coincidence, also introduced a new, albeit different, catheter device, the positive pressure mechanical valve from Alaris. Upon closer examination, Bradley and the other investigators noticed several similarities between the previously reported cases and Hopkins' new one. Alarmed by their findings, the Hopkins team immediately ordered a return to use of the previous valve, one that does not contain the positive-pressure feature, but also has no known risks for causing infection. Almost immediately after the switch, bloodstream infections on the PICU decreased to previous baseline levels. The improvement was so dramatic that by February 2005, the Hopkins team issued recommendations to discontinue use of the new valves throughout the hospital and for all staff to switch back to the older models.
This case marks the second time within a year that Hopkins experts have found risks of infection related to introduction of new medical devices. In December 2004, the Hopkins team reported in the Journal of the American Medical Association on the need for tighter controls surrounding use of a water-gun device for cleaning wounds, since less-strict handling of the device led to a series of bloodstream and wound infections in 11 patients.