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

Background: 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. Methods: 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. Results: 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. Conclusion: This case study highlights the utility of statistical process control in the surveillance and investigation of CA-BSI.