HospitalInspections.org

Based on direct observation, as compared with current hospital standards of practice procedure, staff interviews, and a review of current statistical data of infections, the infection control officer failed to include ancillary personal in hand hygiene training for managing indwelling venous catheters.

The hospital reported a current census of 38 patients on the first survey day.

Findings:

A. During direct observation of Patient # 30 on 4/26/11 at 3:45 PM, who was undergoing a CT scan (Computerized Tomography - a type of imaging anatomical information from a cross sectional plane of the body) for a possible pulmonary embolus (blood clot in the lung) with dye contrast (to improve the imaging), had a PIC line (Peripherally inserted central venous catheter- used for venous access for prolonged periods of time to administer medications, or remove blood samples).

B. During this observation, a Radiology Technologist A was observed touching the equipment above the patient, without gloves, and proceeded to access the patient's PIC line and connect the line to the intravenous (IV) dye contrast solution, without gloves and without hand washing prior to touching the PIC line or the IV solution.

C. Immediately after this observation, and interview with the Radiology Supervisor confirmed that hand washing and the use of gloves was not performed by the Radiology Technologist.

D. The current procedure for managing venous lines labeled, "Administering Medications by Intravenous Bolus." page 617 specifies, prior to starting the administration:
1. "Perform hand hygiene"
6. "Apply clean gloves" -"Reduces transmission of microorganism..."
after administration:
10. "Remove clean gloves and perform hand hygiene"

E. An interview conducted with the Infection Control Officer on 4/28/11 at 9:00 AM revealed the Hospital conducted training sessions for the nursing staff regarding hand hygiene while accessing central venous lines, however, these training sessions failed to include personnel from ancillary departments such as Radiology, Nuclear Medicine, Radiation Oncology, who also access these PIC lines for medication administration.

F. The Centers for Disease Control (CDC) reported in June, 2010 " An estimated 248, 000 blood stream infections occur in the U.S. Hospitals each year...Bloodstream infections are usually serious infections typically causing a prolongation of hospital stay and increased cost and risk of mortality."

G. According to the most recent Clinical Quality report, the hospital reported 2 central venous line infections within the last year.