Unless you’re completely without feeling, I would hazard a guess that when you hear of something bad happening to a child be it abuse or neglect, injury or disease or even death your heart hurts a little. Many of us cannot fathom having a deathly ill child. I’ve been lucky, but I have a close friend whose son at the age of 19 months was diagnosed with a very rare cancer. The treatment was long, hard, and heartbreaking, and made worse by the fact that my friend was also a childhood cancer survivor so knew exactly what his son was going through. I’m happy to say that Liam beat the odds and while he remains cancer free, he will continue to be closely monitored.
While not a brand new issue, heater-cooler units that are used during heart surgeries to regulate the temperature of patients on bypass continue to plague Infection Preventionists, since they are difficult to disinfect, but much needed machines that have been the root cause of several outbreaks. The most recent I’ve read about impacted 12 patients at a children’s hospital who underwent cardiac surgery this summer. The outbreak was blamed on a single heater-cooler unit used in a single operating room.
Patients exhibited signs of surgical site infections including swelling, wound drainage, redness and fever caused by Mycobacterium abscessus. This bacterium is an environmental bacteria that is routinely found in water, soil and dust and while perhaps not the most common bacteria to cause SSIs, it has been known to contaminate medications and other products including medical devices. Transmission of this bacterium generally occurs by injections of substances contaminated with the bacterium or through invasive medical procedures such as open heart surgery that use medical devices, equipment or material that is contaminated with the bacteria.
In order to ensure more patients were not infected the hospital has replaced the heater-cooler device and completed a thorough cleaning and disinfection of the operating room to remove any chance of future environmental contamination. As for the 12 patients infected, while they have all been hospitalized, the good news is that some are very close to going home!
This story parallels the story of duodenoscopes. As we improve our ability to develop more and more technically savvy instruments that can aid in the treatment of patients we increase our risk of developing instruments that are more difficult or nearly impossible to reprocess in a way that we can ensure they are safe to use on the next patient. I’m not saying that we should halt innovation. What I am saying is that we should, when bringing these devices into our facilities, consider conducting validation studies to ensure that we can safely reprocess in a manner that is reproducible each and every time. My motto is if we would not use the device on a loved one, we should not use it on a patient!