Episode 71
71: Outbreak Investigation
It’s time for an outbreak investigation of several MRSA cases in a NICU! Join Annabelle de St. Maurice, Carol Vance, and Allison Bartlett as they take you through the steps of your hospital epidemiologist and infection preventionist team members!
Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com
Transcript
Hi everyone.
Sara Dong:Welcome to Febrile, a cultured podcast about all things infectious disease.
Sara Dong:We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management.
Sara Dong:I'm Sara Dong, your host and a Med-Peds ID fellow.
Sara Dong:And surprise, this episode comes to you a week early in honor of the SHEA (Society of Healthcare Epidemiology of America) 2023 Spring Conference, which will be running from April 11th to 14th.
Sara Dong:A big thanks to Annabelle for leading this episode.
Sara Dong:Annabelle de St.
Sara Dong:Maurice recently took a position as a Physician Specialist in the Acute Communicable Disease Control Unit at the Los Angeles County Department of Public Health.
Sara Dong:She was previously an Associate Professor of Pediatric infectious Diseases and Co-chief Infection Prevention officer at UCLA Mattel Children's Hospital.
Sara Dong:She also joins us as a representative of the SHEA Pediatric Leadership Council, so we're super excited to share this learning episode to give you a flavor of outbreak investigation and infection control in honor of the SHEA Conference.
Annabelle de St. Maurice:Hi, really happy to be here.
Sara Dong:Next I'll introduce Carol Vance, who is the multi-site Director of Infection Prevention for Advocate Aurora Children's Hospital and Interim Christ Medical Center in Park Ridge, IL.
Sara Dong:Carol has had many years of nursing experience in the areas of critical care and infection prevention, and she has been very active in the Association for Professionals in Infection Control and Epidemiology.
Carol Vance:Hi, happy to be here
Sara Dong:And our last guest today.
Sara Dong:We're joined by Dr.
Sara Dong:Allison Bartlet, who is an Associate Professor of Pediatrics in the Section of Infectious Diseases at the University of Chicago Comer Children's Hospital.
Sara Dong:She serves as the Associate Medical Director of Infection Prevention and Control, and was recently appointed Chief Quality Officer for Comer Children's.
Sara Dong:She is also active in SHEA, including the Pediatric Leadership Council.
Sara Dong:I mentioned just a moment.
Allison Bartlett:Hi.
Allison Bartlett:Excited to be here.
Sara Dong:So I'm very excited for today's episode because we have a different type of consult question and a different type of team here today, but to sort of keep it in our usual spin, today's consult question is actually from a NICU team who called in and said, you know, we have several patients that unexpectedly have positive M R S A cultures.
Sara Dong:And so for a little bit more detail.
Sara Dong:You today are the hospital epidemiologist, and you've gotten this call from the neonatal ICU or NICU on a Friday because you know these things always happen on Fridays and you're notified that there are two babies with respiratory cultures positive for MRSA.
Sara Dong:But they were known to be MRSA negative on admission, and so the NICU is pretty worried because they weren't expecting this.
Sara Dong:The cultures were both obtained during sepsis rule outs, although neither of the babies was thought to have any sort of invasive infection.
Sara Dong:Um, just to add, this unit is a level 3-4 NICU with six pods with seven open beds.
Sara Dong:So one pod has an eighth bed and four pods have one isolation room, and the patients were screened for MRSA on admission to the NICU.
Sara Dong:So before we ask a little bit about whether this is a big deal or not or what to do next, Carol, can you set the scene for us and tell a little bit about what the NICU environment's like, uh, what should sort of be running through our heads right now?
Carol Vance:Absolutely.
Carol Vance:Well, I would say from an infection prevention standpoint, getting this call, we're already taking that big sigh and going, ok, we know we have a big journey ahead of us.
Carol Vance:So just to start off, it's important to know what type of environment you're gonna be working in, especially with the neonates.
Carol Vance:So NICU pods, so that is more of a, I guess you could say similar to a congregate setting.
Carol Vance:That's a huge room with multiple, uh, babies in it.
Carol Vance:They each have their own space, their own equipment, and It can look very different.
Carol Vance:Some pods have the nurses station just outside.
Carol Vance:Um, some pods have the nurses station right in the middle.
Carol Vance:So it's very important to understand what your pod looks like, and that is really gonna determine how you navigate through this process.
Carol Vance:And also one thing that is very good that we're starting to see the trend is, is actually single patient, uh, NICU rooms.
Carol Vance:And so that actually mitigates a huge amount of the risk that you'll hear about in this podcast.
Carol Vance:But, um, there still are the NICU pods.
Carol Vance:And so what goes along with that is the big room and the multiple babies is there's a lot of equipment that these babies need.
Carol Vance:And so with a lot of equipment and nurses going back and forth, there's lots of opportunity to, um, transfer microorganisms from, you have the diaper scale, you have stethoscopes, you have, um, sometimes they have quilts.
Carol Vance:In the, um, NICU pods, I always try to get rid of those, um, or make sure they have the, uh, a washing process in place that is approved by infection prevention.
Carol Vance:Also, there's multiple different types of beds, so you not only have an incubator, you could have a crib depending on how, um, large this baby is.
Carol Vance:Some of these babies stay months and months depending on what's going on with them.
Carol Vance:And then there's also milk refrigerators, there's bottle warmers, there's um, trays to dry the bottles.
Carol Vance:There's a lot of equipment and usually, especially in the pod area, there's not a lot of space to put it.
Carol Vance:So, um, it's important to know what each area looks like and what, um, type of equipment is to be expected in that area.
Carol Vance:And some of the pods are meant for our babies that are, they're small baby units, so the lights are dim and
Carol Vance:so that also can potentially impact what you can see, the cleaning and that aspect.
Carol Vance:And also with hand hygiene.
Carol Vance:Hand hygiene looks very different when it comes to the pod, um, setup because with that pod setup you have to have very special delineations on what each patient space is.
Carol Vance:There's not necessarily a wall and a door that you have to pass to go in to see the baby, so it's very important that you have your alcohol hand dispensers in a location where whoever is working on the baby can actually have those readily available.
Carol Vance:Then also with, um, the NICU patient population that you don't necessarily see in the adult is, parents actually doing skin to skin where they have their infant on their chest.
Carol Vance:And so that's another important component where they're sitting and are they next to the isolette.
Carol Vance:So there's a lot of different variables just in the environment in itself that as an infection preventionist and as a NICU nurse, physician and ID physician, it's really important that all of those variables are considered in a, when you get this type of call.
Annabelle de St. Maurice:Wow, Carol.
Annabelle de St. Maurice:That's a lot.
Annabelle de St. Maurice:Um, there sounds like there's a lot of potential for transmission.
Annabelle de St. Maurice:I know that there have been a lot of groups that have really worked on trying to reduce transmission.
Annabelle de St. Maurice:Allison, can you tell us a little bit about practices that NICU have in place that are unique to reduce transmission within the NICU and assess for colonization with Staph?
Allison Bartlett:Absolutely.
Allison Bartlett:And, uh, as with many things in pediatric infectious diseases and the NICU in general, much of what we do does not have a strong, uh, evidence base behind it.
Allison Bartlett:Uh, we are trying to get more scientific about that.
Allison Bartlett:And we do have some recent publications, both, um, guidelines from the C D C and then a expert opinion commentary from the Society for Hospital Epidemiology to help share best practice as we wait for more information.
Allison Bartlett:But at this moment, practices are all over the place in terms of units that screen once or twice a week for just MRSA or all Staph aureus or just on admission or just outborn infants.
Allison Bartlett:So there's this broad array of sort of standard practices that are in place.
Allison Bartlett:And then there are also, uh, sort of recommended screening practices when you're concerned about an outbreak, which is sort of the situation that we find ourselves in.
Allison Bartlett:So regardless of what our unit's practice has been leading up to where we are, when we get the call, um, you know, we have now potential concern for more than one case.
Allison Bartlett:And there's a little bit more, um, homogeneity about how we proceed with that part of the investigation.
Allison Bartlett:The other things that we do sometimes, uh, in terms of decolonization of infants that are known to be positive varies.
Allison Bartlett:Some institutions decolonize Staph aureus, MSSA and MRSA.
Allison Bartlett:We don't have a lot of good data on C H G bathing, especially in our extremely premature infants,
Allison Bartlett:and their, uh, very delicate, permeable skin.
Allison Bartlett:Contact precautions as well is something that some units do regardless of whether they have MRSA or M S S A in babies.
Allison Bartlett:And again, this is sort of variable and can depend also on whether you're concerned about an outbreak situation at any given time.
Annabelle de St. Maurice:Great.
Annabelle de St. Maurice:So it sounds like there's a lot of variability and, uh, not necessarily a lot of strong evidence in this area.
Annabelle de St. Maurice:So when you get a call like this, Alison, how do you go about determining whether or not this number of cases or this situation is really unexpected or just something we see because this population is so unique?
Allison Bartlett:So, you know, that's a great question.
Allison Bartlett:We certainly know that Staph aureus colonization happens in babies because it happens in older people too.
Allison Bartlett:. And we know that both M R S A and M S S A can cause infections.
Allison Bartlett:So is this more than we would expect to see in our unit?
Allison Bartlett:Is this something that we need to be worried about?
Allison Bartlett:This fits into our, our standard outbreak investigation, uh, model that we can sort of walk through and we'll, we'll talk through this in order, as if there is an order, but really what's happening frantically behind the scenes is all of these things are happening essentially simultaneously by different members of the team, uh, working together.
Allison Bartlett:So the first is to see is this an increase in the number of cases compared to what we usually see?
Allison Bartlett:Or for sometimes if there's an outbreak, is it an unusual pathogen that even just one occurrence is going to make you concerned?
Allison Bartlett:And if you look back in this unit and you realize this is more clinical cases of M R S A than we have had in months or years, and it's probably worth thinking through.
Allison Bartlett:So the next thing to do is develop a case definition.
Allison Bartlett:So what are we calling this population of concern?
Allison Bartlett:And that can change over time as you get into your investigation.
Allison Bartlett:For starters with this case, right, it would be a baby who's currently in this NICU with MRSA identified on either a screening culture or a clinical culture, and, um, you know, this is probably the point at which you would think in your unit.
Allison Bartlett:If you are not a unit that's screening weekly, gosh, we probably need to screen all of our babies to see who else has MRSA.
Allison Bartlett:This is where the setup of your unit comes into place.
Allison Bartlett:Is it all babies in the same pod?
Allison Bartlett:Is it all babies in the entire nicu?
Allison Bartlett:You can sort of start small and get bigger if you need to.
Allison Bartlett:Um, certainly when we go around doing this, we need to come up with some messaging for our staff and ff staff and for our nurses, um, and I'm sorry, our nurses and our parents, so that they understand what we are doing, why we are swabbing their, uh, child.
Allison Bartlett:And we tend to use phrases like out of an abundance of caution, right?
Allison Bartlett:Just be extra careful for your baby.
Allison Bartlett:Um, and, uh, sort of work on how we can communicate with our teams to let them know what's going on.
Allison Bartlett:So if we do a round of screening cultures on all the babies in the nicu, we get a better sense of how many are truly colonized, and that helps us decide whether we have a widespread problem, uh, or just a small cluster.
Allison Bartlett:So, you know, with this kind of extra number of cases, sending a, a selection of sampling cultures on all of the babies we do usually, um, nose, axilla and groin, uh, to get all of the common sites, uh, would probably be the way to go for the next step of investigation.
Annabelle de St. Maurice:How do you come up with a timeframe for your case definition?
Allison Bartlett:Yeah.
Allison Bartlett:So I think that's really important to how far are we going to look back, uh, over the course of time in our unit.
Allison Bartlett:Uh, and I've had the experience where I've looked back for several months and not seen an abnormality.
Allison Bartlett:Then you look back 18 months and you, you, you do see concerns.
Allison Bartlett:Uh, you know, I think that especially for a unit that's doing routine surveillance for Staph aureus, you know, it's pretty easy to get your hands on the last year's worth of data which is you know, a reasonable, uh, period of time to look, uh, back.
Allison Bartlett:And if it's a more rare organism, you may need to look back a, a longer time, or if it's a smaller population, right.
Allison Bartlett:So luckily we have a giant, as all NICU are, nicu.
Allison Bartlett:Um, and so you really can get a pretty decent denominator by looking back about a year.
Allison Bartlett:That's just see the pattern and then right from your sort of outbreak timeframe, you'll get a sense then when there was an uptick in cases.
Allison Bartlett:Um, and I would sort of start my, make that my case definition, patients have had this case since whatever the date of the first cluster of cases was.
Annabelle de St. Maurice:Right.
Annabelle de St. Maurice:And I think the other thing to consider too is the specimen source, right?
Annabelle de St. Maurice:Um, are you going to look at only invasive isolates from sterile sites or your surveillance swabs as well?
Annabelle de St. Maurice:I was also wondering, you know, at, as you know, I've made a transition to a new position at the health department, so I'm curious, you know, when you're doing this type of outbreak investigation, at what point do you let the health department know, and are there any ramifications of letting them about this type of situation
Carol Vance:no, that's a great question actually, and it's something that's really important to make sure that as a hospital epidemiologist and also an infection preventionist, that you know your local and state regulations, that is really what's going to guide you to know what, when to actually report and also what kinda communication that looks like.
Carol Vance:So, um, there's really no ramifications to it because this is a fluid process and you want to make sure that you have the support from your local health department.
Carol Vance:And sometimes they may know about other outbreaks that other NICUs and sometimes they can connect the dots.
Carol Vance:So it's really important to make sure, you know, when cause.
Carol Vance:The ramification is if you don't do it and you're supposed to do it.
Carol Vance:So, um, yeah, we usually find them very helpful in navigating and we use them also to, if we have questions or any concerns, a lot of times they can pull in their experts too.
Annabelle de St. Maurice:Thanks, Carol.
Annabelle de St. Maurice:Yeah, I, I think that's exactly what, um, we, at the Health Department would say as well.
Annabelle de St. Maurice:So I, I really appreciate that and it is a collaborative approach.
Annabelle de St. Maurice:So you're waiting for the culture results.
Annabelle de St. Maurice:It's Saturday and you're notified that there's an infant who has an MRSA infection at the site of a PIV insertion, and there's MRSA growing from a pustule.
Annabelle de St. Maurice:You also get the results back from your first round of screening and you realize you have four additional babies with MRSA colonization.
Annabelle de St. Maurice:Two are from the pod of one case.
Annabelle de St. Maurice:One is from the pod of the second case, and the case that had the infection at the P I V site and one is in a different pod.
Annabelle de St. Maurice:And you find out that there were two babies who had positive clinical cultures two and five months before this event because you went back during the past six months to see if you had other babies who had MRSA infections and that both of those babies had screened negative prior to those clinical cultures.
Annabelle de St. Maurice:This is a lot of information, Allison, but what would you do with this information?
Annabelle de St. Maurice:How would that change the way you approach this outbreak?
Allison Bartlett:The, this, this is a very realistic case and these are coming at you, sort of these pieces of data fast and furious.
Allison Bartlett:So the way that I take a, you know, a look at this is, There's a couple groups of babies in same, you know, in co-located pods that may all have, uh, M R S A on their, you know, on their screening tests.
Allison Bartlett:And we need to figure out whether these are potentially related and also stop ongoing transmission if it's happening.
Allison Bartlett:We don't wait until we know for sure if these cases are related.
Allison Bartlett:While we are doing the investigation, we're simultaneously working on what we can do to help, um, stop transmission.
Allison Bartlett:We may end up, uh, interrupting the source of transmission before we ever find it and don't have an explanation for this.
Allison Bartlett:The ultimate goal is to stop the transmission and prevent other infections.
Allison Bartlett:So we have to learn how to live with that.
Allison Bartlett:We don't always have a pump handle to remove.
Allison Bartlett:So one of the things that we'll do now that we have multiple cases is start our line list.
Allison Bartlett:Um, so we, um, are gonna have a list of the patient and their date of admission and their gestational age and what bed they are currently in and potentially what bed spaces they have been in along the way, um, there's a lot of movement that happens in the neonatal ICU.
Sara Dong:You know, I was helping out with actually one of our IPCs recently to just look into a couple cases that a surgeon called us about, and I think I didn't really know how to approach what to put on a line list is, um, any sort of tips on what, what you can include and, and what you leave out and how you avoid making a super extensive list of maybe more info than you need.
Carol Vance:Sure.
Carol Vance:And I think Alison definitely, um, we could tag team this question.
Carol Vance:The important component is making sure that you identify the physical location and having which beds they were in, the timeframe.
Carol Vance:You wanna identify when they were, always when they were admitted, cuz you wanna know the length of stay.
Carol Vance:Um, also the type of positive culture.
Carol Vance:Was it a swab for colonization?
Carol Vance:Was it an active infection?
Carol Vance:Sometimes it may be important to identify also what is going on with the infant, um, if it is actually specifically affecting certain type of patients.
Carol Vance:Alison, what would you, um, also put on there?
Carol Vance:Did I miss some big stuff?
Allison Bartlett:This is where outbreaks to outbreaks depend.
Allison Bartlett:We were less concerned about a common source outbreak, but we still did look at the medication lists for the patients.
Allison Bartlett:I didn't necessarily put every medicine on the line list, but as I was starting to formulate my case definition, I looked at that.
Allison Bartlett:Um, I think your point about what is happening to the patient, right?
Allison Bartlett:Is it only in intubated patients?
Allison Bartlett:And then I'm going to think a little bit differently and maybe want to know what kind of ventilator they had.
Allison Bartlett:You know, what kind of respiratory therapy in interventions they were having.
Allison Bartlett:And so it is, it was sort of knowing what potential fields you could pull in and which ones make sense for this, right?
Allison Bartlett:This investigation.
Allison Bartlett:Did they go to the OR?
Allison Bartlett:It helps just look at a, a few of the cases and get a sense for what common themes may be.
Allison Bartlett:And then you may discover something, you know, on your fifth case and have to go back and, and add a column to your line list and, and that's okay.
Allison Bartlett:Um, cuz it's always a very fluid process.
Annabelle de St. Maurice:It all goes back to the scientific method and having a hypothesis right.
Sara Dong:Yeah, exactly.
Sara Dong:So where should we go to continue our investigation?
Allison Bartlett:It sounds like additional screening might be warranted.
Allison Bartlett:We may want to send these isolates for typing of some sort, whether you are a lab like mine that still does pulse field gel electrophoresis, or you have access to a more exciting technology like whole genome sequencing.
Allison Bartlett:It can help determine whether there is potential relatedness between these strains.
Allison Bartlett:We want to make an epidemic curve, a list of the sort of cases that are happening over time and space.
Allison Bartlett:Again, babies move around, uh, a lot and in terms of, interrupting transmission, we will want to put the babies who have screened positive on contact isolation.
Allison Bartlett:Consideration can be given also to cohorting, uh, babies that screen positive again in a pod, depends on your unit setup.
Allison Bartlett:We want to make sure that we're doing our due diligence around the unit in terms of our hand hygiene practices and our incubator cleaning practices.
Allison Bartlett:Think about collecting environmental samples and whether, uh, that is something that you would like to embark upon, and then continue frequent open communications with the frontline staff.
Allison Bartlett:Uh, they may have fantastic ideas about a source potentially that you have, uh, overlook.
Annabelle de St. Maurice:That's really helpful.
Annabelle de St. Maurice:And I don't know, Carol, if you have any comments too about some of the environmental sampling, um, and some of the limitations of that.
Annabelle de St. Maurice:Um, and maybe also, you know, at what point do you think about gasp swabbing staff?
Annabelle de St. Maurice:Because, uh, I know that, um, just as Allison mentioned, um, and you mentioned, you know, staff have a lot of contact with these babies.
Annabelle de St. Maurice:Are there ever times when you think about doing that, um, and you know, the limitations of that or maybe some of the challenges with doing so.
Carol Vance:No, those are great questions.
Carol Vance:Um, before I answer those questions, I did wanna add a little insight to, from an infection prevention standpoint on, it sounds very linear, what we've said, right?
Carol Vance:We have mentioned it can all, it can come at different times, and from different people, but, one thing that's really important is to keep a cool head when this first starts.
Carol Vance:Mm-hmm.
Carol Vance:Um, you'll find, uh, that there are several people who usually want to go really, really fast and, um, maybe are a little, a too anxious.
Carol Vance:And you need to calm them down.
Carol Vance:Sometimes it's, you know, you're a NICU manager or you may have a new neonatologist that you have to coach and walk them through.
Carol Vance:Cause the most important thing is to be calm and be very judicious on how you take your steps.
Carol Vance:Um, you can easily go off on a tangent that could take you down a rabbit hole
Carol Vance:you don't wanna go.
Carol Vance:So with that being said, um, it's very important to talk to your colleagues around, cuz you're talking to your EVS, your managers, usually your charge nurse.
Carol Vance:And as an infection preventionist, it's kind of our job to try to be as much of a gatekeeper to the ID because we need the ID MD to really be focusing on epidemiology of it, the clinical aspects, talking to physicians.
Carol Vance:Really, we work as a partner to make sure that we are setting up all the pertinent information so that they can clinically take a look and make those important decisions.
Carol Vance:So from a mitigation standpoint, when we talk about surveillance cultures of, um, the environment, I internally do a little shrug and a sigh because when, when that is brought up and there are absolutely appropriate times to be doing it, so it's not that, it's not an appropriate and effective measure to do.
Carol Vance:You want to make sure you have all your ducks in a row before you do that.
Carol Vance:What you want to not do is go.
Carol Vance:With the first person that says we need to culture all the chairs, all the sinks, all the um, the countertops.
Carol Vance:And actually, no, there's very, um, important steps that you have to follow if you are going to be doing that type of mitigation strategy or
Carol Vance:collection of data.
Carol Vance:And so I really, usually at this point in time, the health department is really involved.
Carol Vance:If we're getting to the point where we're gonna be culturing something other than the baby.
Carol Vance:Um, especially with staff members, um, I highly recommend if you have an outbreak that is that significant,
Carol Vance:usually consulting with the, um, Department of Health.
Carol Vance:They usually will give you the, okay, you need to proceed with this or you don't, um, depending on how well your health department is active with this type of outbreak.
Carol Vance:I just always throw caution cause when you test, you'll find, and it's very important to understand that, um, the first steps of your outbreak, that you have a clear definition, you know exactly what you're looking for so that you stay on task.
Carol Vance:So from, from an IP standpoint, you know, the mitigation of it, just as, um, Alison had mentioned, a lot of times we will actually inadvertently stop it even before we know, which is great because one of your first things is to stop the transmission.
Carol Vance:There's many different tactics.
Carol Vance:It is important that one of the mitigation strategies is to ensure that, uh, the unit is following the appropriate isolation strategies and depending on what type of organism.
Carol Vance:So, um, ensure that the unit has the appropriate setups to actually allow their team members to successfully put on the appropriate PPE.
Carol Vance:And it's also important to make sure that with the contact isolation, that you have clearly designated areas for each patient station or it patient area so that there is no overlapping between the two, um, or more patient.
Allison Bartlett:A, and I think to your point, Carol, uh, isolation can be a mitigation strategy for pathogens that we would not otherwise usually use contact precautions for.
Allison Bartlett:Right.
Allison Bartlett:As a means of interrupting, uh, potential transmission.
Carol Vance:Exactly.
Carol Vance:So co cohorting the MRSA babies.
Carol Vance:So putting those babies, especially if you have a pod, you don't have four walls to separate between the babies.
Carol Vance:So that also increases the potential risk of transmission.
Carol Vance:So you wanna separate all of those babies that are known to be positive, um, and then also make sure that you know who has potentially been exposed.
Carol Vance:So having that criteria laid out so you know what babies you are maybe doing additional checks on, especially if they've been exposed or met the definition.
Carol Vance:Then from an IP perspective, I really always, when I'm training new IPs, I tell them to kinda step back and watch what goes on in the nicu.
Carol Vance:Watch how the team members actually go from space to space.
Carol Vance:Where are they doing their hand hygiene?
Carol Vance:Where, how does e v s flow through?
Carol Vance:How do the physicians flow through?
Carol Vance:Because this is really going to help you pinpoint where you wanna focus.
Carol Vance:Um, and lot of that can come also with accompaniment of audits.
Carol Vance:So hopefully the unit has hand hygiene audits that you can see.
Carol Vance:Um, they may have high touch audits, so you can tell if the compliance is high.
Carol Vance:You may have a, a compliance of hand hygiene that's a hundred percent.
Carol Vance:And you have a M R s A transmission issue.
Carol Vance:You know, hand hygiene is not a hundred percent.
Carol Vance:So you take those with a grain of salt and you use what your current observations are to detect, um, where you need to focus.
Carol Vance:Um, some of the things, as we mentioned before, you know, when they have, when they're in the isolates, there's port holes that they're constantly touch.
Carol Vance:So these high touch areas and are they doing their hand hygiene, cleaning off the portals also, um, making sure touching base with EVS.
Carol Vance:Sometimes if you have an E V S team that is less comfortable or they're new, they may be more apprehensive going into closer areas around the isolette.
Carol Vance:Also, if there's not a lot of counter space, the counters could be really cluttered, and if they're really cluttered, then the EVS can't get in there to clean.
Carol Vance:So looking at those components to see how nursing or whoever the, the team members are, are helping facilitate the EVS, get in there to do appropriate clean.
Carol Vance:Also looking at what type of, um, uh, separation do you have?
Carol Vance:Do you have disposable curtains?
Carol Vance:Do you have wipeable curtains?
Carol Vance:Are these, um, are they appropriately managed based on the policy and the protocol that you have?
Carol Vance:And cleaned appropriately.
Carol Vance:Um, also, where do you have your cleaning wipes?
Carol Vance:Are they easily accessible?
Carol Vance:Um, can anybody get to them?
Carol Vance:Do they understand?
Carol Vance:Can the nurses and the staff actually speak to the cleaning process and when it should be cleaned and, um, when they can be used?
Annabelle de St. Maurice:Those are really great points, Carol.
Annabelle de St. Maurice:I think it's so important to have those partners within the hospital, and I think really talking to the people rather than just looking at logs of cleaning is often really important too, because once you talk to someone, uh, you really find out the details about, uh, what's been going on in real life.
Annabelle de St. Maurice:Now going back to our case, um, it turns out we do our PFGE screening and we find out that five of seven isolates are identical.
Annabelle de St. Maurice:There are several environmental samples that are obtained after the cleaning that you recommended that are growing staph aureus, but we actually don't have additional information just yet.
Annabelle de St. Maurice:And then we find out that there are three new M RSA positive babies that were identified in the second point prevalence survey cultures.
Annabelle de St. Maurice:So the cultures that we did of all the babies that were in our nicu.
Annabelle de St. Maurice:So I wanna pause for a second.
Annabelle de St. Maurice:Um, I wanna ask Allison a little bit more about kind of our, uh, technology behind these quote unquote matches.
Annabelle de St. Maurice:And how do you determine when to ask the lab to do?
Annabelle de St. Maurice:Um, sequencing and what type of sequencing to do.
Annabelle de St. Maurice:And I know you mentioned that your lab does pfge, but you know, I'm sure within, um, our.
Annabelle de St. Maurice:Uh, network of hospitals and fellows, we have other opportunities to do whole genome sequencing and other testing.
Annabelle de St. Maurice:So tell us a little bit more about that in your experience.
Allison Bartlett:Sure.
Allison Bartlett:, it is a, uh, a resource we would love to all have access to is whole genome sequencing of everything.
Allison Bartlett:But, but when is it important to pull the, you know, the trigger, what other information is there?
Allison Bartlett:And part of it is organism specific.
Allison Bartlett:So an incredibly unusual organism that shows up more than once,
Allison Bartlett:that may be enough information.
Allison Bartlett:Uh, it may be that, uh, if you have several gram negatives, but their resistance patterns are different, that's enough to be reassuring as opposed to if they all have the same resistance pattern and you may want to look into it more.
Allison Bartlett:You know, with something as common as staph aureus, it's tricky to, uh, distinguish.
Allison Bartlett:Right.
Allison Bartlett:Whether these are unrelated events because we know they can happen.
Allison Bartlett:Um, but really having additional relatedness information of however you can get it, uh, can be really powerful in, in determining whether we're concerned about transmission from patient to patient or from patient to fomite.
Allison Bartlett:You know, to healthcare worker, hand to patient, uh, or any of the steps along the way.
Allison Bartlett:And so there's, like you said, a very, uh, a variety of technologies that we can use, all of which help get us to that sort of relatedness, uh, and level of concern we have about transmission events happening.
Annabelle de St. Maurice:That makes sense.
Annabelle de St. Maurice:And I think, at least in my experience, having a very close relationship with your microbiology lab is also really important because sometimes they're the ones who actually let us know about outbreaks before we even realize they're happening.
Allison Bartlett:I, I think that's, you are so correct that the.
Allison Bartlett:Infection prevention is a team sport, but it's not just a team sport of infection preventionist and ID right specialists.
Allison Bartlett:It's interfacing with all of the unit frontline staff and our E V S teams and our sort of micro uh, colleagues.
Allison Bartlett:And it really is, everyone has an important role.
Allison Bartlett:Uh, I know my microlab would not be happy if I sent down a swab on each of the 70 NICU babies without giving them a headsup to expect those, uh, right.
Allison Bartlett:So there's a lot of collaboration that's happening with that group.
Annabelle de St. Maurice:That's great.
Annabelle de St. Maurice:So now that you have information that these isolates are identical either through pfge or whole genome sequencing and you have these three new cases, what are you gonna do?
Annabelle de St. Maurice:What are you thinking at this point?
Allison Bartlett:So I'm getting increasingly concerned at this point that we have something going on.
Allison Bartlett:Um, we hopefully put into place some, uh, cleaning and EVs related interventions.
Allison Bartlett:We've probably ramped up our hand hygiene observations.
Allison Bartlett:I want to continue to do that and see if we've made, um, you know, an, an impact on our, uh, cleanliness practices.
Allison Bartlett:You know, one thing that is less common as a source for a Staph aureus infection is some of the other shared, you know, medications or formula, things like that need to be considered a possible common source.
Allison Bartlett:But the other piece that we have not yet investigated, and now as we're getting more, uh, cases, despite our attempts at preventing transmission, is to think about whether there could be a staff member, uh, who is, uh, colonized or is a, a super spreader of some sort.
Allison Bartlett:So along the way, you know, Looked at which staff members have taken care of which babies.
Allison Bartlett:But again, this is just ends up being a social network web, uh, in the neonatal I c u and we can only know from what's documented on, but the number of nurses who help out their colleague when they go to lunch and interact with a baby who's, you know, they've not documented on the chart, really makes these investigations difficult.
Allison Bartlett:I worry less about a parent as a common source because of course, Parents are usually only attached to one or two or three babies.
Allison Bartlett:Um, so we in conjunction with our, our local health department, talked through at what point do we think about right screening our staff?
Allison Bartlett:And it's important to, to have this discussion with the staff.
Allison Bartlett:This is not a punitive thing, right?
Allison Bartlett:If we were to identify a staff member who was positive, um, we would decolonize them, but they're not going to lose their job.
Allison Bartlett:And we're not saying that they did anything wrong.
Allison Bartlett:Uh, but it is important to, to do the messaging, and I've, I've found that the NICU teams are so dedicated to what they do, that those, uh, conversations are relatively easy to, to have
Annabelle de St. Maurice:yeah, that makes sense.
Annabelle de St. Maurice:And that probably also I would imagine, involves a discussion with your hospital leadership and maybe some, um, members of the legal team, et cetera, before you go about something like that.
Annabelle de St. Maurice:Right.
Allison Bartlett:Absolutely.
Allison Bartlett:Absolutely.
Allison Bartlett:And it also required us to decide who we count as the NICU staff.
Allison Bartlett:Right.
Allison Bartlett:The bedside nurses is easy, uh, but the res are, you know, pot of respiratory therapists and the residents who are working there and our nurse practitioners.
Allison Bartlett:And it can get a, to be a pretty significant, uh, group.
Allison Bartlett:Right.
Annabelle de St. Maurice:And volunteers.
Annabelle de St. Maurice:Yeah.
Annabelle de St. Maurice:Can really get out of scope pretty quickly.
Annabelle de St. Maurice:And I think that goes back to Carol's point about really making sure to always go back to your hypothesis and thinking about, um, what exactly you're trying to figure out what your question is.
Annabelle de St. Maurice:So let's fast forward to the end of this investigation.
Annabelle de St. Maurice:Uh, your pfge typing ended up identifying three clusters of two to five babies each, and the two environmental samples matched the first five babies.
Annabelle de St. Maurice:However, only about 2% of your staff ended up testing positive for MRSA.
Annabelle de St. Maurice:And actually good news, none of them matched any of the infant strains.
Annabelle de St. Maurice:We can all exhale there.
Annabelle de St. Maurice:Um, and what do you make of this information, Carol?
Annabelle de St. Maurice:Is this what you were expecting?
Annabelle de St. Maurice:Is this kind of unusual when you're doing these types of outbreak investigations?
Carol Vance:Absolutely not.
Carol Vance:This is not surprising at all.
Carol Vance:Um, many times you actually can't pinpoint exactly what it is, but you do have things that do correlate to, uh, what potentially happened.
Carol Vance:So it's really important to understand that while you're going through this, there are many things that you have already implemented and there are many things that you need to implement simultaneously.
Carol Vance:Sometimes you can't tell which one of those things were the potential stop of the transmission.
Carol Vance:So, um, it's not surprising at all.
Carol Vance:I think that when we talk about this and not necessarily having that smoking gun, the important components to think about is getting back to the basics and making sure that your basics are always covered and are consistently being done at an effective, um, compliance rate.
Carol Vance:Because if you have those in place then sometimes it's easier to actually parcel out other variables because you know you have your basics in place, so that's your hand hygiene.
Carol Vance:What does that look like?
Carol Vance:There's so many different ways to improve hand hygiene.
Carol Vance:It doesn't have to just be an actual physical audit.
Carol Vance:They now have technology out there that can help assist to actually give an electronic hand hygiene compliance number.
Carol Vance:Also, parents, parents.
Carol Vance:Very important to ensure not only that they visit asymptomatic, that they don't have any type of illness coming in, but that they understand the importance of hand hygiene and also phone hygiene.
Carol Vance:Many times we walk around and the parents are holding the babies and holding their phone, taking a picture, texting back and forth, and making sure that they understand that they need to clean their phones too, because phones are some of the dirtiest things that we can bring into the NICU.
Carol Vance:Um, and then also just making sure that, um, there are visual cues to remind our parents and our employees or team members, um, when to do it and how often to do it.
Carol Vance:So with that being said, when I say the basics, uh, the basics are always long-term.
Carol Vance:Um, long-term mitigation strategies, those shouldn't go away.
Carol Vance:Your hand hygiene and cleanliness of the environment should always be your baseline and should always be frequently checked in with, because there are things, as we just learned through the pandemic that.
Carol Vance:Sometimes there's not enough staff to do everything.
Carol Vance:So it's important to have that clear communication and checking to see when, um, either there's a dip in compliance and, you know, focusing the attention to bring it back up.
Carol Vance:Last thing to think about redundancies.
Carol Vance:So when I say that, don't have cleanliness based on one touchpoint, right?
Carol Vance:So the EVs, environmental services, they will come and they'll clean.
Carol Vance:But it's not just environmental services, it's actually the team members also taking this, the appropriate hospital approved, um, wipes.
Carol Vance:And actually doing additional cleaning because there are times we are human and it's human to err
Carol Vance:so having those redundancies built in.
Carol Vance:So if in case at one point in time there is a miss, there's always another redundancy built in to come, come in and um, uh, pick up where the miss had happened.
Carol Vance:. Annabelle de St. Maurice: So, Alison, is this surprising to you?
Carol Vance:Were you expecting to find, you know, the typhoid Mary of your Staph aureus outbreak or, you know, the pump handle as you referred to earlier that was covered in Staph.
Allison Bartlett:No, this is, uh, un excitingly what I was expecting to find.
Allison Bartlett:I have yet to have an aha moment and have a unifying explanation for, you know, outbreaks that we have.
Allison Bartlett:Really, this did seem to be sort of global lapses in our standard practices, um, you know, in, in multiple areas by multiple people.
Allison Bartlett:And, uh, it feels like every several years, um, we do some sort of investigation like this in the neonatal I C u.
Allison Bartlett:And in all, in all honesty, one of the reasons.
Allison Bartlett:That I'll tend to push for an investigation when it may not be necessary is because I suspect there's still an opportunity there to improve our, um, you know, baseline practices, use it as a refresher course.
Allison Bartlett:Um, there's probably been turnover in our e v s staff and having time to talk with them about.
Allison Bartlett:How important what they're doing is, um, and you know, sort of reinforcing that, that role, making sure that they have all the supplies they need to do their job, making sure that the things that our nursing staff are responsible for cleaning are, are being done.
Allison Bartlett:Um, And, and sort of a, almost a relationship and team building that exercise that has benefits beyond interrupting the transmission of this event, uh, that is happening.
Annabelle de St. Maurice:Yeah.
Annabelle de St. Maurice:It sounds like those redundancies that Carol talked about are really important to prevent these types of things from happening and Yeah, I agree.
Annabelle de St. Maurice:I feel like in my experience, it's very rare that we identify, you know, the heater cooler that led to the NTM outbreak.
Annabelle de St. Maurice:You know, the ultrasound gel, you know, that's contaminated, but it is very satisfying when you do.
Annabelle de St. Maurice:But I agree, it's seems like it's very rare.
Annabelle de St. Maurice:Do you have any other thoughts about this outbreak that either of you would like to share or any tips maybe for those interested in infection prevention?
Allison Bartlett:Well, I think that, you know, if, if any of this investigation or puzzle solving or, team sport activity sounds fun to anyone.
Allison Bartlett:I'm sure that your local hospital epidemiologist and infection prevention team, um, we're always willing to have more people come to the fun, uh, of doing these, uh, outbreak investigations.
Allison Bartlett:It's a different way of, of looking at the world.
Annabelle de St. Maurice:I agree, and I think that the, if I would just add anything, I think the type of people that go into infection prevention, public health, just as you mentioned Carol, we tend to really be very collegial and I think also, um, very calm because as you mentioned, if you get too carried away at the beginning, then uh, you can get yourself down certain rabbit holes that maybe aren't super productive.
Sara Dong:Yeah, I love the emphasis on truly being a team sport and like a really lar, not that we don't work with multidisciplinary teams in a consult setting, but I think this is a whole different group of communities of people who are taking care of patients in different ways that you may not get exposure to when you're just doing your.
Sara Dong:Um, I guess I should say more routine Id care.
Sara Dong:And I think this episode, hopefully people will, uh, you know, we emphasize that all these steps often are happening at the same time, but I think having a sense of what the general.
Sara Dong:Uh, framework or steps in an outbreak investigation are, is very useful and we'll definitely have to make a graphic on that.
Sara Dong:I'm sure the CDC has some, um, but we'll make a febrile one.
Sara Dong:Um, and I think a lot of, I was gonna mention, I think a lot of the fellows do the shea, um, healthcare epi, stewardship mo uh, curriculum that's online now.
Sara Dong:Um, and there's definitely some good sections in there going over a lot of these topics too.
Annabelle de St. Maurice:Yeah.
Annabelle de St. Maurice:And I think.
Annabelle de St. Maurice:Fellows are often welcome to join their infection control committee at the hospital too, and we.
Annabelle de St. Maurice:When I was at ucla, we actually had an elective where fellows would rotate through infection prevention.
Annabelle de St. Maurice:They actually got a tour of the hospital, um, which, you know, sounds boring, but actually when you go back and see, uh, with engineering the way the water and the air is filtered and all the things that could potentially go wrong, or you meet with the EVs director, learn about all of the things that Carol talked about, then I think it's really kind of impressive.
Annabelle de St. Maurice:Uh, Um, it takes to just admit a patient to the hospital.
Sara Dong:Yeah, I, I was saying before we started recording that I'm on my, um, this is like my second go through for my hospital epi infection control rotation, and there's a bunch of construction at our hospital, so going on environment of care rounds and, and learning about what people.
Sara Dong:Looking at and thinking about it's, it's like a totally different perspective than, um, anything that I would've been thinking about over the past couple months.
Sara Dong:That was really cool.
Annabelle de St. Maurice:Our fellows often cite it as their favorite rotation.
Sara Dong:Yeah.
Sara Dong:Well, any other closing thoughts?
Allison Bartlett:It turned out that even though we found all of these additionally colonized babies, there were no other, uh, clinical infections at all.
Allison Bartlett:So this ended up being a purely colonizing early detection.
Allison Bartlett:No babies were harmed in the making of this movie.
Sara Dong:Thanks to Annabelle, Carol, and Alison for this awesome episode.
Sara Dong:I hope that this can be a nice complement if you're attending the SHEA conference, working on your infection control rotation, or just learning about a new topic.
Sara Dong:Don't forget to check out the website, febrile podcast.com to find the Consult Notes, which are written complements to the show with links to references, our library of ID infographics and the link to our merch store.
Sara Dong:Please reach out if you have any suggestions for future shows, or want to be more involved with Febrile.
