When Barnes-Jewish Hospital, in St. Louis, introduced a closed system drug-transfer device (CSTD) in six oncology wards in 2016, the intention was to protect vascular access teams from exposure to toxic antineoplastic drugs. What happened instead was a significant increase in central line–associated bloodstream infections (CLABSIs).
Why that unintended consequence occurred and how the hospital’s Infection Prevention (IP) Department brought the rate back to normal is