Outbreak

Control
Strategy
Course
QuorumVeda Consulting
Services LLP

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Atypical Mycobacteria
Outbreak in a Maternity
Home: A Timeline
Overview
Day 0 - Patient Zero

•Case 1, a new mother post-Cesarean section.

•Wound not healing as expected.
•Shows signs of infection: pus discharge, redness,
pain.
•Hospital staff becomes concerned.
•The outbreak's first alarming signal.
Day 7 - Initial Concerns Arise
Two additional cases emerge from the same unit.
These patients also exhibit nonhealing surgical sites with pus discharge.
Concerns intensify as the outbreak seems to be spreading within the unit in the hospital.

Break out rooms

The Obstetrician is worried and calls for a meeting
Who are the stakeholders involved?
1. What immediate actions should be taken in response to the two new cases?
2. How can effective communication with patients and families be maintained during this crisis?
3. What measures can be taken to investigate the infection source and prevent further spread within
the hospital?
Stakeholders
• Hospital Administration
• Infection Control Team
• Obstetrician
• Nursing Staff
• Affected Patients and Families
• Environmental Services
• Laboratory and Microbiology Department
• Hospital Epidemiologist
Discussion
and Action
Immediate Action
Points

1. Emergency Meeting & Notification

2. Patient Isolation & Care
3. Protocol Enhancement
4. Contact Tracing
5. Surveillance & Hygiene
6. Visitor Restriction
Communication
with Patients and
Families
• Plan Development
• Designated Staff
• Regular Updates
• Psychological Support
• Address Concerns
• Transparency
Day 14- Media Report

• The situation takes a new turn as media reports surface.

• Headlines: "hospital outbreak sparks public concern."
• Media blames the hospital for negligence.
• Allegations of inadequate care during maternity packages.
• Trust in the hospital is significantly shaken.
Mitigation with Media
• Breakout room

• What immediate steps should the hospital take to address the negative
media coverage and rebuild public trust?

• How can the hospital effectively communicate its commitment to patient

safety and transparency in light of the media allegations?

• What strategies can be employed to regain the trust of affected patients

and their families who may have been impacted by the outbreak and
media reports?
Investigating the Infection Source
• Collaboration
• Sample Collection
• Review Surgical Procedures
• Equipment Inspection
• Consider External Factors
• Staff Practices
Root Cause Analysis and Corrective
Actions
• Root Cause Analysis
• Findings-Based Actions
• Enhanced Protocols
• Training and Education
• Monitoring and Surveillance
• Transparency
 Diagnostic Workup and Targeted Therapy

• Initiate Line Listing of cases

• Diagnostic Workup:
• Gram Stain
• Modified ZN Stain
• AFB Culture
• Targeted Therapy:
• Tailored treatment based on drug susceptibility results
Day 15 - New Cases in Surgery Unit 2

• A concerning development emerges.

• Three new cases surface in Surgery Unit 2.
• These cases involve patients who underwent two hernia repairs and one
laparoscopy procedure.
• Instrument culture swabs were taken from the respective operating theaters.
• Notably, routine bacterial swabs from all possible surgical instruments
returned negative results.
• CSSD protocols remain intact.
• The investigation expands as these new cases contribute to the puzzle.
Differing
Perspectives and
Roles
• Surgeon: Chance occurrence,
“Probable contaminant”
• Obstetrician: Believes in a
“Definite source”
• Microbiologist: Investigative
("Sherlock Holmes").
• Hospital Epidemiologist:
Collaborates ("Dr. Watson").
• Administration: Seeks answers for
“Patient safety”.
Breakout Room
• How to bridge surgeon and obstetrician perspectives for a comprehensive investigation?
• What strategies can enhance the integration of microbiologist and hospital epidemiologist roles in
surveillance?
• What strategic approach can facilitate communication among stakeholders to streamline
surveillance procedures and resolve the outbreak efficiently?
Day 30- Crucial Discovery

Crucial Discovery:
Laboratory results confirm Mycobacterium fortuitum isolate in scrub room tap and water.
Significantly narrows down the source of infection.
Initiated Actions:
Water Tank Cleaning and Conversion to RO Water
• Cleaning and Disinfection
• Conversion to RO Water
• Periodic Testing
Discussion and Action!
Preventing Further Spread
1. Strict Isolation Protocols
2. Rigorous Surveillance and Monitoring
3. Staff Education and Training
4. Auditing Infection Prevention Compliance
5. Patient Cohorting or Relocation
6. Healthcare Worker Movement Control
7. Collaboration with External Health Authorities
Follow-up
• Regular Communication with Stakeholders
• Infection Control Protocol Review and Update
• Ongoing Situation Monitoring
• Sharing Lessons Learned
Special considerations for Atypical
Mycobacteria SSI Outbreak
• Unique Characteristics of Atypical Mycobacteria
• Tailored Infection Control Measures
• Diagnostic Challenges and Testing
• Patient and Staff Education
• Vigilant Surveillance and Monitoring
• Collaborative Approach with Experts
• Community Awareness and Reporting
Documentation
• Comprehensive Record-Keeping
• Future Reference
• Reporting Documentation
• Legal and Liability Support
• Accountability Records
……..time for dinner..