title: A Hospital-wide Outbreak of Serratia marcescens, and Ishikawa's "Fishbone" Analysis to Support Outbreak Control.
abstract: A nosocomial outbreak of Serratia marcescens in respiratory samples predominantly from patients in a surgical intensive care unit is reported. Most of these patients were cardiac surgical patients. Initially, a vigorous but inconclusive investigation was implemented on the basis of standardized (according the US Centers for Disease Control and Prevention) steps of outbreak investigation. Then, a systemic quality management approach with "fishbone" analysis was added. As a consequence, plausible causes for the outbreak were identified: (i) S marcescens was found on the transesophageal echocardiography probe used during cardiac surgery; and (ii) the quality of the surface disinfection was insufficient due to multiple reasons and was completely reengineered. In conclusion, in addition to the standardized steps of outbreak investigation, the complementary use of quality management tools such as the Ishikawa "fishbone" analysis is helpful for outbreak control. The complete reengineering of the disinfectant procurement and logistics is assumed to have been the most effective measure to control the described outbreak.
authors.affiliation: Department of Hospital Infection Control, Lucerne Cantonal Hospital, Lucerne, Switzerland (Ms Vetter and Drs Schuepfer and Rossi); and Division of Infectious Diseases and Hospital Epidemiology, University Hospital and University of Zurich, Zurich, Switzerland (Dr Kuster).
authors.forename: Luzia
authors.initials: L
authors.lastname: Vetter
authors.forename: Guido
authors.initials: G
authors.lastname: Schuepfer
authors.forename: Stefan P
authors.initials: SP
authors.lastname: Kuster
authors.forename: Marco
authors.initials: M
authors.lastname: Rossi
mesh_terms: D003428:Cross Infection / Q000453:epidemiology* / Q000517:prevention & control; D004196:Disease Outbreaks; D006801:Humans; D017053:Infection Control / Q000458:organization & administration*; D007362:Intensive Care Units; D012307:Risk Factors; D016868:Serratia Infections / Q000453:epidemiology* / Q000517:prevention & control; D012706:Serratia marcescens / Q000302:isolation & purification*; D014481:United States