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Geisinger Pseudomonas Outbreak

NICU   (448,678 Views 3 Comments)
by Jolie Jolie, BSN (Member) Member Nurse

Jolie is a BSN and specializes in Maternal - Child Health.

34,863 Profile Views; 6,373 Posts

https://wnep.com/2019/11/08/donor-breast-milk-processing-source-of-geisinger-nicu-infection/

 

This article describes the pharmacy's procedure (or lack thereof) for cleaning equipment used to measure donor breastmilk as hand washing with a brush and air drying. This is blamed for equipment contamination with pseudomonas that led to the deaths of 3 infants and infections of 5 more who survived.

I have not worked in a NICU in over 20 years, but even by the standards of the 1990's dark ages, I can't fathom anyone believing this to be an acceptable practice. Every health department in the country has food service standards requiring dishes be sanitized by heat or chemical processes. And anyone who has passed Microbiology 101 understands the need for infection control precautions for immunocompromised individuals. Yet the "dishwashing" process in Geisinger's pharmacy wouldn't hold up to the standards in most of our homes.

Some of these babies were undoubtedly receiving only a few cc's of donor milk per day. Why were their rations not simply drawn up into disposable syringes or poured into single-use Volufeeders?

My prayers to the families and innocent staff members. Such an easily preventable tragedy.

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adventure_rn is a BSN and specializes in NICU, PICU.

1 Follower; 1 Article; 1,154 Posts; 17,351 Profile Views

What a mess. I agree that this was entirely preventable, and that the process does seem unbelievable given our focus on infection prevention in the NICU. So very sad for those kids and families.

Tangentially related, this is one of the reasons I hate using Dr. Brown bottles. I understand that research finds that the Dr. Brown nipples are the best option for preemies (compared to disposables). However, they're so expensive that most places won't just throw them out after each feed. Every place I've ever worked has had the nurses hand wash and air dry the bottles. They take forever to clean because there are so many bottle parts with tiny nooks and crannies; consequently, they don't get cleaned well enough (since nurses are busy), and they get so disgusting. Then they sit out to air dry in a nasty basin with wet paper towel in the bottom, where they very well could be brewing bacteria. Even if you sterilize them daily with the microwave bags, that's still a full day for bugs to grow, and if you don't manually clean them well enough they're still covered with a sludgy film of MCT oil and breast milk fat even after microwaving. Also, it's not like people are sterilizing the plastic washing/drying basin every day, and people don't think to change those out daily. I feel like it's only a matter of time before kids start getting sick from inadequately cleaned bottles.

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TiffyRN has 26 years experience as a ADN, BSN, PhD and specializes in NICU.

2,284 Posts; 16,036 Profile Views

Re: Dr. Brown's bottles. When we first started using them I went to feed an infant and thought "wow, this must be a really old one because the clear plastic nipple is cloudy". So it was just milk fat because apparently a lot of people (some parents, some nurses) must think that washing a bottle involved rinsing under warm water. The cloudy nipple was incredibly clear once all the milk fat was washed with soap until it was no longer greasy feeling (a matter of seconds given minimal effort). 

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