1 00:00:10,020 --> 00:00:10,830 Sara Dong: Hi everyone. 2 00:00:10,830 --> 00:00:14,910 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:15,000 --> 00:00:19,500 We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. 4 00:00:20,075 --> 00:00:22,625 I'm Sara Dong, your host and a Med-Peds ID fellow. 5 00:00:22,955 --> 00:00:35,495 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. 6 00:00:36,075 --> 00:00:38,805 A big thanks to Annabelle for leading this episode. 7 00:00:38,805 --> 00:00:39,735 Annabelle de St. 8 00:00:39,735 --> 00:00:48,315 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. 9 00:00:48,435 --> 00:00:56,745 She was previously an Associate Professor of Pediatric infectious Diseases and Co-chief Infection Prevention officer at UCLA Mattel Children's Hospital. 10 00:00:57,455 --> 00:01:10,740 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. 11 00:01:11,400 --> 00:01:12,810 Annabelle de St. Maurice: Hi, really happy to be here. 12 00:01:13,530 --> 00:01:23,220 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. 13 00:01:23,655 --> 00:01:34,875 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. 14 00:01:35,640 --> 00:01:37,140 Carol Vance: Hi, happy to be here 15 00:01:37,590 --> 00:01:39,060 Sara Dong: And our last guest today. 16 00:01:39,060 --> 00:01:39,960 We're joined by Dr. 17 00:01:39,960 --> 00:01:48,030 Allison Bartlet, who is an Associate Professor of Pediatrics in the Section of Infectious Diseases at the University of Chicago Comer Children's Hospital. 18 00:01:48,120 --> 00:01:55,570 She serves as the Associate Medical Director of Infection Prevention and Control, and was recently appointed Chief Quality Officer for Comer Children's. 19 00:01:56,130 --> 00:02:00,030 She is also active in SHEA, including the Pediatric Leadership Council. 20 00:02:00,030 --> 00:02:01,080 I mentioned just a moment. 21 00:02:02,054 --> 00:02:02,324 Allison Bartlett: Hi. 22 00:02:02,324 --> 00:02:03,255 Excited to be here. 23 00:02:03,824 --> 00:02:24,615 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. 24 00:02:25,155 --> 00:02:27,075 And so for a little bit more detail. 25 00:02:28,395 --> 00:02:43,935 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. 26 00:02:44,265 --> 00:02:50,505 But they were known to be MRSA negative on admission, and so the NICU is pretty worried because they weren't expecting this. 27 00:02:50,995 --> 00:02:59,125 The cultures were both obtained during sepsis rule outs, although neither of the babies was thought to have any sort of invasive infection. 28 00:02:59,965 --> 00:03:06,955 Um, just to add, this unit is a level 3-4 NICU with six pods with seven open beds. 29 00:03:07,225 --> 00:03:16,265 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. 30 00:03:16,650 --> 00:03:30,750 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? 31 00:03:31,440 --> 00:03:32,280 Carol Vance: Absolutely. 32 00:03:32,700 --> 00:03:44,070 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. 33 00:03:44,220 --> 00:03:51,839 So just to start off, it's important to know what type of environment you're gonna be working in, especially with the neonates. 34 00:03:51,989 --> 00:03:58,859 So NICU pods, so that is more of a, I guess you could say similar to a congregate setting. 35 00:03:58,859 --> 00:04:02,489 That's a huge room with multiple, uh, babies in it. 36 00:04:02,489 --> 00:04:07,670 They each have their own space, their own equipment, and It can look very different. 37 00:04:07,670 --> 00:04:11,510 Some pods have the nurses station just outside. 38 00:04:11,960 --> 00:04:15,470 Um, some pods have the nurses station right in the middle. 39 00:04:15,470 --> 00:04:24,080 So it's very important to understand what your pod looks like, and that is really gonna determine how you navigate through this process. 40 00:04:25,085 --> 00:04:32,595 And also one thing that is very good that we're starting to see the trend is, is actually single patient, uh, NICU rooms. 41 00:04:32,595 --> 00:04:39,165 And so that actually mitigates a huge amount of the risk that you'll hear about in this podcast. 42 00:04:39,615 --> 00:04:42,765 But, um, there still are the NICU pods. 43 00:04:42,825 --> 00:04:49,560 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. 44 00:04:49,950 --> 00:05:06,289 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. 45 00:05:07,080 --> 00:05:18,820 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. 46 00:05:19,479 --> 00:05:29,320 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. 47 00:05:29,320 --> 00:05:33,435 Some of these babies stay months and months depending on what's going on with them. 48 00:05:34,065 --> 00:05:40,065 And then there's also milk refrigerators, there's bottle warmers, there's um, trays to dry the bottles. 49 00:05:40,065 --> 00:05:46,515 There's a lot of equipment and usually, especially in the pod area, there's not a lot of space to put it. 50 00:05:46,725 --> 00:05:57,225 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. 51 00:05:57,225 --> 00:06:05,045 And some of the pods are meant for our babies that are, they're small baby units, so the lights are dim and 52 00:06:05,145 --> 00:06:11,694 so that also can potentially impact what you can see, the cleaning and that aspect. 53 00:06:11,694 --> 00:06:13,429 And also with hand hygiene. 54 00:06:13,429 --> 00:06:26,184 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. 55 00:06:26,484 --> 00:06:43,794 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. 56 00:06:44,594 --> 00:06:56,089 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. 57 00:06:56,419 --> 00:07:01,769 And so that's another important component where they're sitting and are they next to the isolette. 58 00:07:01,789 --> 00:07:17,869 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. 59 00:07:18,199 --> 00:07:18,769 Annabelle de St. Maurice: Wow, Carol. 60 00:07:19,404 --> 00:07:20,184 That's a lot. 61 00:07:20,244 --> 00:07:24,114 Um, there sounds like there's a lot of potential for transmission. 62 00:07:24,664 --> 00:07:29,074 I know that there have been a lot of groups that have really worked on trying to reduce transmission. 63 00:07:29,584 --> 00:07:39,724 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? 64 00:07:41,624 --> 00:07:42,554 Allison Bartlett: Absolutely. 65 00:07:42,554 --> 00:07:52,484 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. 66 00:07:52,934 --> 00:07:55,514 Uh, we are trying to get more scientific about that. 67 00:07:55,514 --> 00:08:10,969 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. 68 00:08:11,299 --> 00:08:25,159 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. 69 00:08:25,159 --> 00:08:30,534 So there's this broad array of sort of standard practices that are in place. 70 00:08:30,924 --> 00:08:41,179 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. 71 00:08:41,179 --> 00:08:53,089 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. 72 00:08:53,389 --> 00:09:00,679 And there's a little bit more, um, homogeneity about how we proceed with that part of the investigation. 73 00:09:02,779 --> 00:09:10,804 The other things that we do sometimes, uh, in terms of decolonization of infants that are known to be positive varies. 74 00:09:10,804 --> 00:09:16,394 Some institutions decolonize Staph aureus, MSSA and MRSA. 75 00:09:16,924 --> 00:09:22,174 We don't have a lot of good data on C H G bathing, especially in our extremely premature infants, 76 00:09:22,174 --> 00:09:25,264 and their, uh, very delicate, permeable skin. 77 00:09:26,434 --> 00:09:32,944 Contact precautions as well is something that some units do regardless of whether they have MRSA or M S S A in babies. 78 00:09:32,944 --> 00:09:40,204 And again, this is sort of variable and can depend also on whether you're concerned about an outbreak situation at any given time. 79 00:09:40,394 --> 00:09:40,694 Annabelle de St. Maurice: Great. 80 00:09:40,694 --> 00:09:49,754 So it sounds like there's a lot of variability and, uh, not necessarily a lot of strong evidence in this area. 81 00:09:50,849 --> 00:10:04,649 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? 82 00:10:06,779 --> 00:10:08,279 Allison Bartlett: So, you know, that's a great question. 83 00:10:08,284 --> 00:10:14,609 We certainly know that Staph aureus colonization happens in babies because it happens in older people too. 84 00:10:14,939 --> 00:10:17,969 . And we know that both M R S A and M S S A can cause infections. 85 00:10:17,969 --> 00:10:21,359 So is this more than we would expect to see in our unit? 86 00:10:22,169 --> 00:10:23,819 Is this something that we need to be worried about? 87 00:10:24,300 --> 00:10:45,704 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. 88 00:10:46,244 --> 00:10:52,544 So the first is to see is this an increase in the number of cases compared to what we usually see? 89 00:10:52,814 --> 00:10:58,454 Or for sometimes if there's an outbreak, is it an unusual pathogen that even just one occurrence is going to make you concerned? 90 00:10:59,114 --> 00:11:09,764 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. 91 00:11:10,334 --> 00:11:13,514 So the next thing to do is develop a case definition. 92 00:11:13,754 --> 00:11:18,404 So what are we calling this population of concern? 93 00:11:18,404 --> 00:11:22,304 And that can change over time as you get into your investigation. 94 00:11:22,844 --> 00:11:38,654 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. 95 00:11:38,684 --> 00:11:46,564 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. 96 00:11:46,874 --> 00:11:49,305 This is where the setup of your unit comes into place. 97 00:11:49,534 --> 00:11:52,050 Is it all babies in the same pod? 98 00:11:52,050 --> 00:11:54,089 Is it all babies in the entire nicu? 99 00:11:54,089 --> 00:11:57,479 You can sort of start small and get bigger if you need to. 100 00:11:58,319 --> 00:12:16,589 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. 101 00:12:16,890 --> 00:12:21,270 And we tend to use phrases like out of an abundance of caution, right? 102 00:12:21,329 --> 00:12:23,969 Just be extra careful for your baby. 103 00:12:24,510 --> 00:12:31,829 Um, and, uh, sort of work on how we can communicate with our teams to let them know what's going on. 104 00:12:33,240 --> 00:12:49,604 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. 105 00:12:51,284 --> 00:13:07,154 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. 106 00:13:08,489 --> 00:13:11,609 Annabelle de St. Maurice: How do you come up with a timeframe for your case definition? 107 00:13:12,314 --> 00:13:12,464 Allison Bartlett: Yeah. 108 00:13:12,464 --> 00:13:19,424 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. 109 00:13:19,784 --> 00:13:24,194 Uh, and I've had the experience where I've looked back for several months and not seen an abnormality. 110 00:13:24,194 --> 00:13:28,124 Then you look back 18 months and you, you, you do see concerns. 111 00:13:28,604 --> 00:13:43,409 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. 112 00:13:43,619 --> 00:13:51,029 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. 113 00:13:51,029 --> 00:13:55,109 So luckily we have a giant, as all NICU are, nicu. 114 00:13:55,379 --> 00:13:59,550 Um, and so you really can get a pretty decent denominator by looking back about a year. 115 00:14:00,329 --> 00:14:08,159 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. 116 00:14:08,489 --> 00:14:18,930 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. 117 00:14:20,084 --> 00:14:20,294 Annabelle de St. Maurice: Right. 118 00:14:20,294 --> 00:14:24,014 And I think the other thing to consider too is the specimen source, right? 119 00:14:24,404 --> 00:14:31,454 Um, are you going to look at only invasive isolates from sterile sites or your surveillance swabs as well? 120 00:14:32,114 --> 00:14:50,839 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 121 00:14:53,129 --> 00:15:15,349 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. 122 00:15:15,349 --> 00:15:26,269 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. 123 00:15:26,274 --> 00:15:32,599 And sometimes they may know about other outbreaks that other NICUs and sometimes they can connect the dots. 124 00:15:32,659 --> 00:15:37,459 So it's really important to make sure, you know, when cause. 125 00:15:37,939 --> 00:15:41,779 The ramification is if you don't do it and you're supposed to do it. 126 00:15:41,869 --> 00:15:53,449 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. 127 00:15:54,709 --> 00:15:55,489 Annabelle de St. Maurice: Thanks, Carol. 128 00:15:55,494 --> 00:16:00,799 Yeah, I, I think that's exactly what, um, we, at the Health Department would say as well. 129 00:16:00,799 --> 00:16:04,459 So I, I really appreciate that and it is a collaborative approach. 130 00:16:05,379 --> 00:16:07,274 So you're waiting for the culture results. 131 00:16:07,304 --> 00:16:17,064 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. 132 00:16:18,014 --> 00:16:26,364 You also get the results back from your first round of screening and you realize you have four additional babies with MRSA colonization. 133 00:16:26,729 --> 00:16:29,429 Two are from the pod of one case. 134 00:16:29,519 --> 00:16:37,379 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. 135 00:16:38,399 --> 00:16:57,645 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. 136 00:16:58,605 --> 00:17:02,714 This is a lot of information, Allison, but what would you do with this information? 137 00:17:02,714 --> 00:17:05,385 How would that change the way you approach this outbreak? 138 00:17:06,464 --> 00:17:12,944 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. 139 00:17:13,244 --> 00:17:32,280 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. 140 00:17:32,550 --> 00:17:41,270 And we need to figure out whether these are potentially related and also stop ongoing transmission if it's happening. 141 00:17:41,620 --> 00:17:45,479 We don't wait until we know for sure if these cases are related. 142 00:17:45,959 --> 00:17:52,649 While we are doing the investigation, we're simultaneously working on what we can do to help, um, stop transmission. 143 00:17:55,019 --> 00:18:03,449 We may end up, uh, interrupting the source of transmission before we ever find it and don't have an explanation for this. 144 00:18:04,604 --> 00:18:07,934 The ultimate goal is to stop the transmission and prevent other infections. 145 00:18:07,934 --> 00:18:10,004 So we have to learn how to live with that. 146 00:18:10,004 --> 00:18:12,074 We don't always have a pump handle to remove. 147 00:18:12,614 --> 00:18:18,225 So one of the things that we'll do now that we have multiple cases is start our line list. 148 00:18:18,735 --> 00:18:36,740 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. 149 00:18:36,995 --> 00:19:00,004 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. 150 00:19:01,215 --> 00:19:01,695 Carol Vance: Sure. 151 00:19:01,905 --> 00:19:06,405 And I think Alison definitely, um, we could tag team this question. 152 00:19:06,715 --> 00:19:17,805 The important component is making sure that you identify the physical location and having which beds they were in, the timeframe. 153 00:19:18,195 --> 00:19:24,620 You wanna identify when they were, always when they were admitted, cuz you wanna know the length of stay. 154 00:19:25,189 --> 00:19:28,399 Um, also the type of positive culture. 155 00:19:28,430 --> 00:19:30,410 Was it a swab for colonization? 156 00:19:30,410 --> 00:19:32,150 Was it an active infection? 157 00:19:32,660 --> 00:19:45,860 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. 158 00:19:46,170 --> 00:19:48,810 Alison, what would you, um, also put on there? 159 00:19:48,810 --> 00:19:50,190 Did I miss some big stuff? 160 00:19:51,460 --> 00:19:53,980 Allison Bartlett: This is where outbreaks to outbreaks depend. 161 00:19:54,370 --> 00:20:00,820 We were less concerned about a common source outbreak, but we still did look at the medication lists for the patients. 162 00:20:00,820 --> 00:20:07,090 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. 163 00:20:07,540 --> 00:20:11,525 Um, I think your point about what is happening to the patient, right? 164 00:20:11,525 --> 00:20:13,655 Is it only in intubated patients? 165 00:20:13,655 --> 00:20:18,635 And then I'm going to think a little bit differently and maybe want to know what kind of ventilator they had. 166 00:20:18,695 --> 00:20:21,425 You know, what kind of respiratory therapy in interventions they were having. 167 00:20:21,425 --> 00:20:28,445 And so it is, it was sort of knowing what potential fields you could pull in and which ones make sense for this, right? 168 00:20:28,475 --> 00:20:29,105 This investigation. 169 00:20:29,375 --> 00:20:30,725 Did they go to the OR? 170 00:20:30,775 --> 00:20:35,455 It helps just look at a, a few of the cases and get a sense for what common themes may be. 171 00:20:35,455 --> 00:20:45,175 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. 172 00:20:45,685 --> 00:20:48,085 Um, cuz it's always a very fluid process. 173 00:20:48,510 --> 00:20:53,100 Annabelle de St. Maurice: It all goes back to the scientific method and having a hypothesis right. 174 00:20:54,170 --> 00:20:55,220 Sara Dong: Yeah, exactly. 175 00:20:55,340 --> 00:20:57,950 So where should we go to continue our investigation? 176 00:20:58,167 --> 00:21:01,197 Allison Bartlett: It sounds like additional screening might be warranted. 177 00:21:01,527 --> 00:21:15,897 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. 178 00:21:15,902 --> 00:21:20,967 It can help determine whether there is potential relatedness between these strains. 179 00:21:21,897 --> 00:21:30,057 We want to make an epidemic curve, a list of the sort of cases that are happening over time and space. 180 00:21:30,117 --> 00:21:43,107 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. 181 00:21:44,277 --> 00:21:51,597 Consideration can be given also to cohorting, uh, babies that screen positive again in a pod, depends on your unit setup. 182 00:21:53,457 --> 00:22:01,467 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. 183 00:22:03,012 --> 00:22:16,482 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. 184 00:22:17,052 --> 00:22:22,352 Uh, they may have fantastic ideas about a source potentially that you have, uh, overlook. 185 00:22:23,397 --> 00:22:24,987 Annabelle de St. Maurice: That's really helpful. 186 00:22:25,037 --> 00:22:32,417 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. 187 00:22:32,447 --> 00:22:38,735 Um, and maybe also, you know, at what point do you think about gasp swabbing staff? 188 00:22:38,957 --> 00:22:47,492 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. 189 00:22:47,492 --> 00:22:56,282 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. 190 00:22:56,852 --> 00:22:58,472 Carol Vance: No, those are great questions. 191 00:22:58,922 --> 00:23:08,012 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? 192 00:23:08,017 --> 00:23:18,597 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. 193 00:23:18,687 --> 00:23:18,777 Mm-hmm. 194 00:23:19,167 --> 00:23:28,857 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. 195 00:23:29,362 --> 00:23:30,562 And you need to calm them down. 196 00:23:30,562 --> 00:23:37,732 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. 197 00:23:38,182 --> 00:23:43,252 Cause the most important thing is to be calm and be very judicious on how you take your steps. 198 00:23:43,642 --> 00:23:48,472 Um, you can easily go off on a tangent that could take you down a rabbit hole 199 00:23:48,472 --> 00:23:49,552 you don't wanna go. 200 00:23:49,917 --> 00:23:59,907 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. 201 00:24:00,267 --> 00:24:16,392 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. 202 00:24:17,892 --> 00:24:27,257 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. 203 00:24:27,767 --> 00:24:47,552 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. 204 00:24:47,942 --> 00:24:51,362 You want to make sure you have all your ducks in a row before you do that. 205 00:24:51,842 --> 00:24:54,222 What you want to not do is go. 206 00:24:54,962 --> 00:25:03,152 With the first person that says we need to culture all the chairs, all the sinks, all the um, the countertops. 207 00:25:03,152 --> 00:25:12,252 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 208 00:25:12,357 --> 00:25:13,587 collection of data. 209 00:25:13,947 --> 00:25:19,167 And so I really, usually at this point in time, the health department is really involved. 210 00:25:19,167 --> 00:25:24,027 If we're getting to the point where we're gonna be culturing something other than the baby. 211 00:25:24,327 --> 00:25:31,407 Um, especially with staff members, um, I highly recommend if you have an outbreak that is that significant, 212 00:25:31,677 --> 00:25:34,947 usually consulting with the, um, Department of Health. 213 00:25:35,217 --> 00:25:45,312 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. 214 00:25:46,082 --> 00:26:02,617 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. 215 00:26:02,667 --> 00:26:18,947 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. 216 00:26:19,337 --> 00:26:20,697 There's many different tactics. 217 00:26:20,827 --> 00:26:33,607 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. 218 00:26:33,917 --> 00:26:46,172 So, um, ensure that the unit has the appropriate setups to actually allow their team members to successfully put on the appropriate PPE. 219 00:26:46,302 --> 00:27:00,522 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. 220 00:27:02,152 --> 00:27:11,142 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. 221 00:27:11,742 --> 00:27:12,072 Right. 222 00:27:12,072 --> 00:27:15,642 As a means of interrupting, uh, potential transmission. 223 00:27:16,752 --> 00:27:17,442 Carol Vance: Exactly. 224 00:27:17,706 --> 00:27:20,406 So co cohorting the MRSA babies. 225 00:27:20,736 --> 00:27:27,306 So putting those babies, especially if you have a pod, you don't have four walls to separate between the babies. 226 00:27:27,426 --> 00:27:31,206 So that also increases the potential risk of transmission. 227 00:27:31,206 --> 00:27:41,436 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. 228 00:27:41,826 --> 00:27:52,471 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. 229 00:27:53,681 --> 00:28:01,841 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. 230 00:28:02,291 --> 00:28:07,421 Watch how the team members actually go from space to space. 231 00:28:07,721 --> 00:28:09,761 Where are they doing their hand hygiene? 232 00:28:09,766 --> 00:28:11,741 Where, how does e v s flow through? 233 00:28:12,041 --> 00:28:13,811 How do the physicians flow through? 234 00:28:13,811 --> 00:28:18,341 Because this is really going to help you pinpoint where you wanna focus. 235 00:28:19,251 --> 00:28:23,481 Um, and lot of that can come also with accompaniment of audits. 236 00:28:23,481 --> 00:28:27,201 So hopefully the unit has hand hygiene audits that you can see. 237 00:28:27,531 --> 00:28:32,871 Um, they may have high touch audits, so you can tell if the compliance is high. 238 00:28:33,091 --> 00:28:37,286 You may have a, a compliance of hand hygiene that's a hundred percent. 239 00:28:37,291 --> 00:28:40,346 And you have a M R s A transmission issue. 240 00:28:40,376 --> 00:28:42,416 You know, hand hygiene is not a hundred percent. 241 00:28:42,596 --> 00:28:50,756 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. 242 00:28:51,206 --> 00:28:58,616 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. 243 00:28:59,101 --> 00:29:08,711 So these high touch areas and are they doing their hand hygiene, cleaning off the portals also, um, making sure touching base with EVS. 244 00:29:08,726 --> 00:29:18,806 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. 245 00:29:20,036 --> 00:29:29,116 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. 246 00:29:29,446 --> 00:29:39,856 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. 247 00:29:41,176 --> 00:29:45,646 Also looking at what type of, um, uh, separation do you have? 248 00:29:45,706 --> 00:29:47,296 Do you have disposable curtains? 249 00:29:47,296 --> 00:29:48,676 Do you have wipeable curtains? 250 00:29:49,066 --> 00:29:55,056 Are these, um, are they appropriately managed based on the policy and the protocol that you have? 251 00:29:55,511 --> 00:29:57,041 And cleaned appropriately. 252 00:29:57,611 --> 00:29:59,831 Um, also, where do you have your cleaning wipes? 253 00:29:59,831 --> 00:30:01,721 Are they easily accessible? 254 00:30:01,781 --> 00:30:03,701 Um, can anybody get to them? 255 00:30:04,001 --> 00:30:04,931 Do they understand? 256 00:30:04,931 --> 00:30:14,231 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? 257 00:30:14,711 --> 00:30:16,601 Annabelle de St. Maurice: Those are really great points, Carol. 258 00:30:16,601 --> 00:30:33,701 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. 259 00:30:34,691 --> 00:30:44,741 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. 260 00:30:45,521 --> 00:30:55,991 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. 261 00:30:55,991 --> 00:31:03,776 And then we find out that there are three new M RSA positive babies that were identified in the second point prevalence survey cultures. 262 00:31:03,776 --> 00:31:07,766 So the cultures that we did of all the babies that were in our nicu. 263 00:31:08,426 --> 00:31:10,436 So I wanna pause for a second. 264 00:31:10,646 --> 00:31:20,276 Um, I wanna ask Allison a little bit more about kind of our, uh, technology behind these quote unquote matches. 265 00:31:20,396 --> 00:31:23,606 And how do you determine when to ask the lab to do? 266 00:31:24,521 --> 00:31:28,301 Um, sequencing and what type of sequencing to do. 267 00:31:28,301 --> 00:31:33,631 And I know you mentioned that your lab does pfge, but you know, I'm sure within, um, our. 268 00:31:34,226 --> 00:31:40,166 Uh, network of hospitals and fellows, we have other opportunities to do whole genome sequencing and other testing. 269 00:31:40,166 --> 00:31:43,346 So tell us a little bit more about that in your experience. 270 00:31:43,946 --> 00:31:44,336 Allison Bartlett: Sure. 271 00:31:44,341 --> 00:31:50,911 , it is a, uh, a resource we would love to all have access to is whole genome sequencing of everything. 272 00:31:50,911 --> 00:31:56,521 But, but when is it important to pull the, you know, the trigger, what other information is there? 273 00:31:56,851 --> 00:32:00,716 And part of it is organism specific. 274 00:32:00,976 --> 00:32:03,856 So an incredibly unusual organism that shows up more than once, 275 00:32:03,856 --> 00:32:05,686 that may be enough information. 276 00:32:06,106 --> 00:32:18,286 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. 277 00:32:18,826 --> 00:32:24,676 You know, with something as common as staph aureus, it's tricky to, uh, distinguish. 278 00:32:25,306 --> 00:32:25,456 Right. 279 00:32:25,486 --> 00:32:28,726 Whether these are unrelated events because we know they can happen. 280 00:32:28,966 --> 00:32:42,586 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. 281 00:32:43,491 --> 00:32:48,081 You know, to healthcare worker, hand to patient, uh, or any of the steps along the way. 282 00:32:48,111 --> 00:33:03,201 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. 283 00:33:05,146 --> 00:33:05,776 Annabelle de St. Maurice: That makes sense. 284 00:33:05,776 --> 00:33:18,616 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. 285 00:33:19,336 --> 00:33:22,336 Allison Bartlett: I, I think that's, you are so correct that the. 286 00:33:23,686 --> 00:33:31,456 Infection prevention is a team sport, but it's not just a team sport of infection preventionist and ID right specialists. 287 00:33:31,456 --> 00:33:38,776 It's interfacing with all of the unit frontline staff and our E V S teams and our sort of micro uh, colleagues. 288 00:33:38,781 --> 00:33:41,176 And it really is, everyone has an important role. 289 00:33:41,446 --> 00:33:51,976 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. 290 00:33:51,976 --> 00:33:54,286 So there's a lot of collaboration that's happening with that group. 291 00:33:55,096 --> 00:33:55,696 Annabelle de St. Maurice: That's great. 292 00:33:56,776 --> 00:34:09,166 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? 293 00:34:09,226 --> 00:34:10,666 What are you thinking at this point? 294 00:34:11,866 --> 00:34:16,336 Allison Bartlett: So I'm getting increasingly concerned at this point that we have something going on. 295 00:34:16,996 --> 00:34:23,611 Um, we hopefully put into place some, uh, cleaning and EVs related interventions. 296 00:34:23,611 --> 00:34:26,461 We've probably ramped up our hand hygiene observations. 297 00:34:26,731 --> 00:34:36,061 I want to continue to do that and see if we've made, um, you know, an, an impact on our, uh, cleanliness practices. 298 00:34:37,081 --> 00:34:51,376 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. 299 00:34:52,066 --> 00:35:08,536 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. 300 00:35:08,626 --> 00:35:15,166 So along the way, you know, Looked at which staff members have taken care of which babies. 301 00:35:15,166 --> 00:35:35,686 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. 302 00:35:36,496 --> 00:35:44,911 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. 303 00:35:45,361 --> 00:35:55,321 Um, so we in conjunction with our, our local health department, talked through at what point do we think about right screening our staff? 304 00:35:55,411 --> 00:36:00,121 And it's important to, to have this discussion with the staff. 305 00:36:00,121 --> 00:36:04,276 This is not a punitive thing, right? 306 00:36:04,276 --> 00:36:12,616 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. 307 00:36:12,616 --> 00:36:14,266 And we're not saying that they did anything wrong. 308 00:36:14,506 --> 00:36:26,666 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 309 00:36:26,666 --> 00:36:28,666 Annabelle de St. Maurice: yeah, that makes sense. 310 00:36:28,666 --> 00:36:39,166 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. 311 00:36:39,166 --> 00:36:39,496 Right. 312 00:36:40,516 --> 00:36:41,386 Allison Bartlett: Absolutely. 313 00:36:41,386 --> 00:36:41,986 Absolutely. 314 00:36:43,396 --> 00:36:47,446 And it also required us to decide who we count as the NICU staff. 315 00:36:48,166 --> 00:36:48,406 Right. 316 00:36:48,411 --> 00:36:56,116 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. 317 00:36:56,121 --> 00:36:59,416 And it can get a, to be a pretty significant, uh, group. 318 00:37:00,046 --> 00:37:00,436 Right. 319 00:37:00,436 --> 00:37:01,456 Annabelle de St. Maurice: And volunteers. 320 00:37:02,416 --> 00:37:02,716 Yeah. 321 00:37:03,526 --> 00:37:05,776 Can really get out of scope pretty quickly. 322 00:37:05,776 --> 00:37:15,966 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. 323 00:37:17,506 --> 00:37:21,016 So let's fast forward to the end of this investigation. 324 00:37:21,196 --> 00:37:31,816 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. 325 00:37:31,996 --> 00:37:36,526 However, only about 2% of your staff ended up testing positive for MRSA. 326 00:37:37,206 --> 00:37:41,296 And actually good news, none of them matched any of the infant strains. 327 00:37:41,296 --> 00:37:45,076 We can all exhale there. 328 00:37:45,136 --> 00:37:48,586 Um, and what do you make of this information, Carol? 329 00:37:48,586 --> 00:37:50,716 Is this what you were expecting? 330 00:37:50,716 --> 00:37:56,266 Is this kind of unusual when you're doing these types of outbreak investigations? 331 00:37:57,241 --> 00:37:58,291 Carol Vance: Absolutely not. 332 00:37:58,501 --> 00:38:00,301 This is not surprising at all. 333 00:38:00,631 --> 00:38:10,161 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. 334 00:38:10,581 --> 00:38:21,201 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. 335 00:38:21,956 --> 00:38:29,306 Sometimes you can't tell which one of those things were the potential stop of the transmission. 336 00:38:30,276 --> 00:38:33,186 So, um, it's not surprising at all. 337 00:38:33,546 --> 00:38:54,306 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. 338 00:38:54,756 --> 00:39:05,331 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. 339 00:39:05,331 --> 00:39:06,531 What does that look like? 340 00:39:06,531 --> 00:39:08,961 There's so many different ways to improve hand hygiene. 341 00:39:09,321 --> 00:39:12,561 It doesn't have to just be an actual physical audit. 342 00:39:12,621 --> 00:39:21,321 They now have technology out there that can help assist to actually give an electronic hand hygiene compliance number. 343 00:39:21,621 --> 00:39:23,091 Also, parents, parents. 344 00:39:23,441 --> 00:39:35,771 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. 345 00:39:36,131 --> 00:39:53,131 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. 346 00:39:53,151 --> 00:40:07,011 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. 347 00:40:07,566 --> 00:40:12,966 So with that being said, when I say the basics, uh, the basics are always long-term. 348 00:40:13,386 --> 00:40:17,676 Um, long-term mitigation strategies, those shouldn't go away. 349 00:40:17,886 --> 00:40:28,386 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. 350 00:40:28,716 --> 00:40:31,266 Sometimes there's not enough staff to do everything. 351 00:40:31,266 --> 00:40:42,786 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. 352 00:40:43,176 --> 00:40:46,566 Last thing to think about redundancies. 353 00:40:47,316 --> 00:40:54,901 So when I say that, don't have cleanliness based on one touchpoint, right? 354 00:40:54,901 --> 00:40:58,471 So the EVs, environmental services, they will come and they'll clean. 355 00:40:58,861 --> 00:41:08,551 But it's not just environmental services, it's actually the team members also taking this, the appropriate hospital approved, um, wipes. 356 00:41:08,811 --> 00:41:14,331 And actually doing additional cleaning because there are times we are human and it's human to err 357 00:41:15,081 --> 00:41:17,631 so having those redundancies built in. 358 00:41:17,631 --> 00:41:29,241 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. 359 00:41:29,781 --> 00:41:32,061 . Annabelle de St. Maurice: So, Alison, is this surprising to you? 360 00:41:32,066 --> 00:41:43,636 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. 361 00:41:43,636 --> 00:41:47,836 Allison Bartlett: No, this is, uh, un excitingly what I was expecting to find. 362 00:41:47,836 --> 00:41:55,996 I have yet to have an aha moment and have a unifying explanation for, you know, outbreaks that we have. 363 00:41:56,386 --> 00:42:06,756 Really, this did seem to be sort of global lapses in our standard practices, um, you know, in, in multiple areas by multiple people. 364 00:42:07,546 --> 00:42:15,826 And, uh, it feels like every several years, um, we do some sort of investigation like this in the neonatal I C u. 365 00:42:16,246 --> 00:42:19,486 And in all, in all honesty, one of the reasons. 366 00:42:20,671 --> 00:42:34,051 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. 367 00:42:34,381 --> 00:42:39,291 Um, there's probably been turnover in our e v s staff and having time to talk with them about. 368 00:42:41,431 --> 00:42:59,131 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. 369 00:42:59,501 --> 00:43:10,681 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. 370 00:43:12,091 --> 00:43:12,271 Annabelle de St. Maurice: Yeah. 371 00:43:12,271 --> 00:43:20,821 It sounds like those redundancies that Carol talked about are really important to prevent these types of things from happening and Yeah, I agree. 372 00:43:20,826 --> 00:43:28,861 I feel like in my experience, it's very rare that we identify, you know, the heater cooler that led to the NTM outbreak. 373 00:43:29,881 --> 00:43:37,561 You know, the ultrasound gel, you know, that's contaminated, but it is very satisfying when you do. 374 00:43:37,591 --> 00:43:41,041 But I agree, it's seems like it's very rare. 375 00:43:42,841 --> 00:43:52,081 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? 376 00:43:52,411 --> 00:44:01,351 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. 377 00:44:01,351 --> 00:44:12,541 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. 378 00:44:12,541 --> 00:44:15,541 It's a different way of, of looking at the world. 379 00:44:16,126 --> 00:44:41,116 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. 380 00:44:42,646 --> 00:45:00,606 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. 381 00:45:01,186 --> 00:45:04,456 Um, I guess I should say more routine Id care. 382 00:45:05,356 --> 00:45:15,696 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. 383 00:45:16,931 --> 00:45:24,131 Uh, framework or steps in an outbreak investigation are, is very useful and we'll definitely have to make a graphic on that. 384 00:45:24,551 --> 00:45:28,061 I'm sure the CDC has some, um, but we'll make a febrile one. 385 00:45:28,571 --> 00:45:39,101 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. 386 00:45:39,491 --> 00:45:43,421 Um, and there's definitely some good sections in there going over a lot of these topics too. 387 00:45:44,621 --> 00:45:44,831 Annabelle de St. Maurice: Yeah. 388 00:45:44,831 --> 00:45:45,311 And I think. 389 00:45:46,161 --> 00:45:53,211 Fellows are often welcome to join their infection control committee at the hospital too, and we. 390 00:45:54,351 --> 00:46:00,411 When I was at ucla, we actually had an elective where fellows would rotate through infection prevention. 391 00:46:00,411 --> 00:46:21,951 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. 392 00:46:22,071 --> 00:46:26,376 Uh, Um, it takes to just admit a patient to the hospital. 393 00:46:27,516 --> 00:46:44,046 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. 394 00:46:44,811 --> 00:46:52,581 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. 395 00:46:52,581 --> 00:46:53,301 That was really cool. 396 00:46:53,901 --> 00:46:57,171 Annabelle de St. Maurice: Our fellows often cite it as their favorite rotation. 397 00:46:57,467 --> 00:46:57,917 Sara Dong: Yeah. 398 00:46:57,917 --> 00:46:59,957 Well, any other closing thoughts? 399 00:47:00,317 --> 00:47:06,827 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. 400 00:47:07,367 --> 00:47:11,267 So this ended up being a purely colonizing early detection. 401 00:47:12,812 --> 00:47:14,702 No babies were harmed in the making of this movie. 402 00:47:20,880 --> 00:47:24,360 Sara Dong: Thanks to Annabelle, Carol, and Alison for this awesome episode. 403 00:47:24,810 --> 00:47:31,950 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. 404 00:47:32,580 --> 00:47:43,110 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. 405 00:47:43,740 --> 00:47:48,060 Please reach out if you have any suggestions for future shows, or want to be more involved with Febrile. 406 00:47:48,330 --> 00:47:50,940 Thanks for listening, stay safe and we'll see you next time.