Striking a balance between freedom and safety on a pediatric bone marrow transplant unit

Abstract

BACKGROUND: The pediatric bone marrow transplant (BMT) unit at this university medical center is a 16-bed inpatient unit. From January 1 through March 19, 2004, 12 cases of adenovirus infection were identified on this unit. Ten of the 12 isolates were a single strain, suggesting nosocomial spread of the organism. METHODS: Cases were identified as patients with signs and symptoms of clinical illness and a positive culture for adenovirus. Medical records of all cases were reviewed. Infection control rounds, unit observations, and staff interviews were performed, and a multidisciplinary outbreak team was convened in order to identify potential factors contributing to the cluster of infections. RESULTS: Potential contributing factors identified included patient use of the unit's lounge/playroom, patient/family use of the unit's washing machine, and suboptimal adherence to isolation and hand hygiene protocols. Prior to control of the outbreak, all patients (including neutropenic patients or those on isolation) were allowed to visit the lounge/playroom to foster psychological well-being. Control measures were implemented. Hand hygiene and isolation precautions were emphasized in staff and parent meetings. No patients were allowed in the lounge/playroom until the outbreak was controlled. Droplet and contact precautions were required for all case patients, and hospital gowns or scrubs were required when patients were out of their rooms. Weekly surveillance cultures were used to identify asymptomatic patients colonized with adenovirus. Pre-BMT screening (nasal and rectal) was initiated for all patients. The outbreak ceased following these interventions. One year later, the policy of barring patients on isolation precautions from the lounge/playroom continues, as does routine screening of pre-BMT patients for adenovirus. LESSONS LEARNED: On the pediatric BMT Unit, direct interactions and contact between patients may have compromised their safety. While fostering the psychological well-being of patients is important, it should not put patients at increased risk of acquiring a potentially fatal infection. Since March 2004, there have been no new clusters of adenovirus identified on this unit. Implementation of restrictions on patient congregation at our facility likely helped control this outbreak. It is important to remember that practices that may impact disease transmission among susceptible patients must be closely reviewed by infection control. BACKGROUND: The pediatric bone marrow transplant (BMT) unit at this university medical center is a 16-bed inpatient unit. From January 1 through March 19, 2004, 12 cases of adenovirus infection were identified on this unit. Ten of the 12 isolates were a single strain, suggesting nosocomial spread of the organism. METHODS: Cases were identified as patients with signs and symptoms of clinical illness and a positive culture for adenovirus. Medical records of all cases were reviewed. Infection control rounds, unit observations, and staff interviews were performed, and a multidisciplinary outbreak team was convened in order to identify potential factors contributing to the cluster of infections. RESULTS: Potential contributing factors identified included patient use of the unit's lounge/playroom, patient/family use of the unit's washing machine, and suboptimal adherence to isolation and hand hygiene protocols. Prior to control of the outbreak, all patients (including neutropenic patients or those on isolation) were allowed to visit the lounge/playroom to foster psychological well-being. Control measures were implemented. Hand hygiene and isolation precautions were emphasized in staff and parent meetings. No patients were allowed in the lounge/playroom until the outbreak was controlled. Droplet and contact precautions were required for all case patients, and hospital gowns or scrubs were required when patients were out of their rooms. Weekly surveillance cultures were used to identify asymptomatic patients colonized with adenovirus. Pre-BMT screening (nasal and rectal) was initiated for all patients. The outbreak ceased following these interventions. One year later, the policy of barring patients on isolation precautions from the lounge/playroom continues, as does routine screening of pre-BMT patients for adenovirus. LESSONS LEARNED: On the pediatric BMT Unit, direct interactions and contact between patients may have compromised their safety. While fostering the psychological well-being of patients is important, it should not put patients at increased risk of acquiring a potentially fatal infection. Since March 2004, there have been no new clusters of adenovirus identified on this unit. Implementation of restrictions on patient congregation at our facility likely helped control this outbreak. It is important to remember that practices that may impact disease transmission among susceptible patients must be closely reviewed by infection control.