Advent Health Celebration in Celebration, Florida experienced a sudden cluster of neurosurgical infections and immediately implemented a collaborative approach to handle the crisis. In particular, they faced an outbreak of the bacterium Serratia marsescens, linked to craniotomy procedures. The Infection Preventionist (IP) played a critical role in responding to this situation in real time, thanks to their embedded role in the Operating Room (OR). Through a rapid systemic response, they were able to contain the outbreak and bring about long-term improvement.
The response process and strategies were shared by Charles Vickery Jr, the Infection Prevention Supervisor at AdventHealth Celebration, and Nicholas DeStefano, the Senior Nurse Manager at the same institution, in an interview with Infection Control Today®. They also presented the information at the Association for periOperative Registered Nurses Global Conference & Expo held in Boston, Massachusetts, from April 5 to 8, 2025. Vickery Jr explained that their presentation, titled ‘Bacteria in the Brain: The Infection Preventionists’ Response,’ was aimed at raising awareness about the importance of collaboration within and across departments in effectively managing crisis situations.
The pre-existing strong relationships within the OR were pivotal during this outbreak. The relationship had been forged through an immersive understanding of surgical workflows and culture by the IP, which had subsequently transformed a potentially tense role into a trusted partnership. This enabled a timely cross-functional response that included neurosurgeons, anesthesia teams, surgical techs, the nursing leadership, sterile processing teams, and the hospital administration. A task force was set up, protocols were reassessed, and improvements were implemented across numerous departments.
Importantly, the outbreak led to the formalization of a role dedicated to infection prevention within the OR. This led to improved proactive, embedded oversight and no additional craniotomy infections being reported since the outbreak in 2021. This success story emphasizes the necessity of early detection, interdisciplinary collaboration, and building constructive relationships between departments. It also serves as a model for other healthcare institutions, showing how integrating infection prevention directly into periop services can bring about cultural change and improved clinical outcomes.