14:26 PM

From Marc Mazade, Medical Director of Infection Control: "Is There Power In A Moment?"

One of our commitments at Cook Children's is “Finding Moments of Magic.” Mazade, MarcA moment is all that is needed to plant a seed of encouragement, to express gratitude, to touch and hug, to clarify a misunderstanding, or to bring joy and fulfillment to a heart.  Taking a moment to prevent an infection expresses that we value others and are concerned about the quality of the care that we provide. I invite you to examine one instance where we may have missed an opportunity to prevent an infection. While reviewing the case think about each time the patient’s central line was entered to diagnose, treat, and ensure resolution of the infection. Think about the additional work that ensued and how the patient might have been harmed.

Last year a young girl was involved in a high-speed motor vehicle accident in which her car collided with a disabled vehicle. She suffered a severe cervical injury. On the second day of her hospitalization our vascular access team placed a left femoral double lumen PICC line after attempting unsuccessfully to place a PICC in the upper extremities. On the tenth day following the accident she developed fever. Her halo pin sites had no drainage. A catheterized UA and urine culture were ordered. Time was required to collect supplies, perform the procedure, collect and apply labels, and send the specimen to the lab. Her morning chest X-ray, secretions, ventilation and oxygenation requirements were reviewed and a tracheal aspirate for gram stain and culture was ordered. PICC line blood cultures from each of the two lumens were ordered. Again this required time to collect supplies, to scrub each hub, collect and apply labels, collect the samples, and send to the bottles to the lab. Vancomycin, which required close monitoring of her renal function, was ordered every 6 hours to treat her infection.

Within 48 hours the lab reported that the white lumen of the CVL had grown gram positive cocci, later identified as Enterococcus faecium. Infectious diseases was consulted and antibiotic coverage was refined. Three more sets of daily blood cultures were ordered. It took 10 days of antibiotics to treat the infection. An echocardiogram was required to rule out endocarditis when she had another fever later.

Our patient’s infection was just one of great number of nationwide preventable hospital acquired infections over the last two years according to a Solutions for Patient Safety (SPS) collaborative review. Increased staff workloads, addition of inexperienced staff to the workforce, and practice drift were found to be the most commonly identified reasons for the huge jump in preventable infections.

 Please answer each of the following questions either True or False:

  • Scrubbing the central line hub for 30 seconds and waiting 30 more seconds for it to dry might have prevented our patient’s central line from having to be accessed as many as 46 times.
  •  This preventable infection required treatment with antibiotics that have risk of causing acute kidney injury and the infectious could have resulted in a heart valve infection.
  •  Avoiding practice drift from line placement and maintenance bundles can make Zero Harm an achievable goal.

 Answers: Are All True.

SPS CLABSI Special Cause Investigation Report

There is power in moment!