Phlebotomy as a Source of Clostridium septicum Gas Gangrene

ISSUE: Phlebotomy is often performed by personnel without nursing or infection prevention education. Infection Control (IC) was notified regarding a potential Clostridium septicum gas gangrene inoculation in an outpatient phlebotomy setting. A 70-year-old patient expired 52 hours after receiving phlebotomy. The patient presented to an outside facility with pain and swelling of the right antecubital space. After the diagnosis of a gas-producing infection, the patient quickly decompensated and later expired. PROJECT: Infection control professionals (ICPs) were given the opportunity to assess practice, policy, and environmental conditions within an area often overlooked in large tertiary-care facilities. RESULTS: ICPs observed breaks in aseptic technique by numerous staff. Skin-preparation technique was noted as inadequate. First, staff did not sanitize their hands between clients. Second, the initial alcohol prep was not allowed to dry, preventing appropriate antisepsis. Finally, site recontamination occurred during palpation of the antecubital site with ungloved, unwashed hands. It was noted that the medical supply storage area was untidy and that supplies were not kept the proper distance from the floor. Educational inservices on proper patient skin preparation and proper specimen collection were conducted. Waterless hand sanitizer was installed to make proper hand hygiene more accessible. Direct feedback of these observations was given to the staff. LESSONS LEARNED: Outpatient areas like phlebotomy should not be overlooked as financial and time constraints may cause personnel to neglect appropriate technique. Infection control practices and principles should be reviewed with phlebotomy personnel on a routine basis.