Playing Catch-up: What Happened When I Made the Wrong Call

Session Description: It’s not easy being an Infection Preventionist (IP). We are considered experts on transmission-based precautions and colleagues rely on us to give accurate information. So, what happens when we are wrong?

This education follows the extremely complex and non-traditional presentation of Mycobacterium tuberculosis (TB) complex in a teenager. The case is presented interactively with the audience, highlighting where isolation decisions were made. Documentation of the multiple diagnostic labs, procedures, radiology, and the difficulty in identifying the specific species of Mycobacterium are included in the presentation. After case presentation, we will focus on where IP could have made better or different choices, knowing now what the outcome was. This includes identifying when to begin an exposure work-up, timing of communications inside the organization and with the Department of Health, and the importance of collaboration with Employee Health. Over forty healthcare workers (HCW) were identified to have had high-risk exposure and over thirty were baseline tested for TB via Tuberculin Skin Test. Only twenty-one returned for follow-up (61%). There were no conversions.

Not everything went poorly! IP’s partnership with the Infectious Diseases team was a huge win in this difficult situation and the strong bond is highlighted. Additional relationships that IP built throughout multiple departments led to improved trust as the case was being worked up. A communication tool is presented to clearly and quickly communicate important information. A focus on the new partnerships made during this incident round out the wins from this case. The conclusion will contain a summary of lessons learned and a reminder that while IPs might be superheroes, we are only human after all.