The Importance of Transferring Accountability for Infection Control Practices to the Direct Care Providers: Lessons Learned from a Neonatal Intensive Care Unit Outbreak of Pseudomonas aeruginosa

BACKGROUND: An investigation was initiated when the microbiology laboratory notified Infection Control (IC) of an increase in Pseudomonas aeruginosa (PA) from our 50-bed level-III neonatal intensive care unit (NICU) in a 5-week period. METHODS: IC performed record reviews of all PA patients, verified direct care provider (DCP) practices by observation and questioning the staff, reviewed written practice guidelines for the NICU and respiratory staff, and performed a variety of patient and environmental surveillance cultures. All PA isolates were submitted for strain characterization by cell wall fatty acid analysis. RESULTS: Review of the NICU microbiology data disclosed that from January 1–September 30, 2003, there had been only four episodic cases of PA. From October 8–November 12, 2003, six patients were identified; four had bloodstream infection (BSI) with three deaths. Surveillance cultures on December 2, 2003, identified a seventh patient. All patients with PA overlapped in their hospital stays and four of seven (4/7) were in the same nursery. All PA isolates had the same antibiogram and were confirmed to be a single strain. All environmental cultures were no growth. The results of the investigation were shared with the NICU faculty and staff. Guidelines were developed to control the outbreak. Inservice was provided to all shifts by IC and Staff Development for the NICU. IC emphasized the importance of holding all DCPs accountable for adherence to the guidelines. The NICU staff was empowered to demand compliance by all consult and ancillary service staff. IC performed weekly surveillance cultures of the patients. Since December 2, 2003, there have been no new patients with PA. CONCLUSION: We identified a single strain of PA causing an outbreak of cross infection in the NICU. Prevention of cross infection requires compliance with IC practices. Multiple disciplines provide specific skills to these patients, and the frequent contacts that occur between the patient and the DCP increases the risk of cross infection. We believe that transferring accountability for IC practices to the DCP was significant in controlling the outbreak.