Improving Use of Sterile Water for Oral Care and Tube Flushes in Pediatric Intensive Care Units

BackgroundFrom June to July 2014, four patients in our intensive care units (ICUs) grew Elizabethkingia meningoseptica from respiratory cultures. Investigation of the cluster included a review of products that could serve as potential sources, including sterile water. Our policy calls for sterile water for oral care in ICU patients and for discarding opened bottles within 24 hours.MethodsWe conducted an anonymous on line survey of all nurses in 4 ICUs (pediatric medical/surgical, medical, cardiac, and neonatal) regarding use of sterile water for oral care and flushing enteral tubes. We cultured 20 environmental sources and products, including 1 unopened and 2 in use sterile water bottles. Patient isolates underwent pulse field gel electrophoresis (PFGE) to determine relatedness.ResultsOf 509 eligible nurses, 166 (33%) completed the survey; 69% reported at least 6 years in critical care nursing. Nearly all used sterile water for oral care and flushing medications through enteral tubes; 52% also used it for cleaning suction catheters. 21 (13%) respondents using sterile water for oral care reported dipping a toothbrush into the bottle; of these, 4 (19%) reported having done so after use in the patient’s mouth. 55 (30%) respondents using sterile water in enteral tubes reported putting the syringe into the bottle; of these, 11 (20%) reported having done so after flushing a tube.69% reported always labeling an opened bottle with date/time, and 35% reported always performing hand hygiene before opening a bottle. PFGE of the isolates revealed unique chromosomal patterns. No non-clinical cultures grew E. meningoseptica. Two in-use water bottles grew four other organisms.ConclusionsImprovements are needed to standardize sterile water use in pediatric ICUs and should focus on hand hygiene, labeling bottles, and not putting items into bottles after patient use. Contamination of in-use water bottles could serve as a source of outbreaks. BackgroundFrom June to July 2014, four patients in our intensive care units (ICUs) grew Elizabethkingia meningoseptica from respiratory cultures. Investigation of the cluster included a review of products that could serve as potential sources, including sterile water. Our policy calls for sterile water for oral care in ICU patients and for discarding opened bottles within 24 hours. From June to July 2014, four patients in our intensive care units (ICUs) grew Elizabethkingia meningoseptica from respiratory cultures. Investigation of the cluster included a review of products that could serve as potential sources, including sterile water. Our policy calls for sterile water for oral care in ICU patients and for discarding opened bottles within 24 hours. MethodsWe conducted an anonymous on line survey of all nurses in 4 ICUs (pediatric medical/surgical, medical, cardiac, and neonatal) regarding use of sterile water for oral care and flushing enteral tubes. We cultured 20 environmental sources and products, including 1 unopened and 2 in use sterile water bottles. Patient isolates underwent pulse field gel electrophoresis (PFGE) to determine relatedness. We conducted an anonymous on line survey of all nurses in 4 ICUs (pediatric medical/surgical, medical, cardiac, and neonatal) regarding use of sterile water for oral care and flushing enteral tubes. We cultured 20 environmental sources and products, including 1 unopened and 2 in use sterile water bottles. Patient isolates underwent pulse field gel electrophoresis (PFGE) to determine relatedness. ResultsOf 509 eligible nurses, 166 (33%) completed the survey; 69% reported at least 6 years in critical care nursing. Nearly all used sterile water for oral care and flushing medications through enteral tubes; 52% also used it for cleaning suction catheters. 21 (13%) respondents using sterile water for oral care reported dipping a toothbrush into the bottle; of these, 4 (19%) reported having done so after use in the patient’s mouth. 55 (30%) respondents using sterile water in enteral tubes reported putting the syringe into the bottle; of these, 11 (20%) reported having done so after flushing a tube.69% reported always labeling an opened bottle with date/time, and 35% reported always performing hand hygiene before opening a bottle. PFGE of the isolates revealed unique chromosomal patterns. No non-clinical cultures grew E. meningoseptica. Two in-use water bottles grew four other organisms. Of 509 eligible nurses, 166 (33%) completed the survey; 69% reported at least 6 years in critical care nursing. Nearly all used sterile water for oral care and flushing medications through enteral tubes; 52% also used it for cleaning suction catheters. 21 (13%) respondents using sterile water for oral care reported dipping a toothbrush into the bottle; of these, 4 (19%) reported having done so after use in the patient’s mouth. 55 (30%) respondents using sterile water in enteral tubes reported putting the syringe into the bottle; of these, 11 (20%) reported having done so after flushing a tube.69% reported always labeling an opened bottle with date/time, and 35% reported always performing hand hygiene before opening a bottle. PFGE of the isolates revealed unique chromosomal patterns. No non-clinical cultures grew E. meningoseptica. Two in-use water bottles grew four other organisms. ConclusionsImprovements are needed to standardize sterile water use in pediatric ICUs and should focus on hand hygiene, labeling bottles, and not putting items into bottles after patient use. Contamination of in-use water bottles could serve as a source of outbreaks. Improvements are needed to standardize sterile water use in pediatric ICUs and should focus on hand hygiene, labeling bottles, and not putting items into bottles after patient use. Contamination of in-use water bottles could serve as a source of outbreaks.