Controlling an Unprecedented Outbreak with Vancomycin-Resistant Enterococcus faecium in Germany, October 2015 to November 2019.

Hospital outbreaks with vancomycin-resistant enterococci (VRE) pose a serious health threat and a challenge to infection prevention and control (IPC). We herein report on a VRE outbreak of unprecedented extent in Southern Germany (October 2015-November 2019). We used descriptive epidemiology and whole-genome sequencing (WGS) for a detailed outbreak investigation. Of the 2905 cases, 2776 (95.3%) were colonized, whereas from 127 (3.7%), VRE could be isolated from otherwise sterile body fluids or sites unlikely for enterococci colonization. Cases had a median age of 78 years (IQR 68-84) and 1339/2905 (46%) were female. The majority of isolates sequenced belonged to the clonal lineage ST80/CT1013 (212/397, 53%). Nosocomial transmission was observed as well as the constant import of VRE into the hospital. Extensive IPC measures were implemented and terminated the outbreak in late 2019, eventually. Our study shows that the combination of epidemiological and genomic analyses is indispensable for comprehensive outbreak investigations. The adaptation of IPC measures to these findings, their timely implementation, and strict execution also allow containment of large VRE outbreaks in hospital settings.

Qualitative process analysis and modelling of emergency care workflow and interface management: identification of critical process steps.

OBJECTIVES: Over the past few years, the number of patients attending emergency services has increased steadily. As a result, emergency departments (EDs) worldwide face frequent crowding, with the risk of reduced treatment quality and impaired patient outcome, patient and staff dissatisfaction and inefficient use of ED resources. A qualitative process analysis and process modelling was used as a method to detect critical process steps in the ED with respect to time and efficiency. METHODS: The analysis was carried out by independent external process experts. Over a period of 1 week, the complete treatment process of 25 patients was recorded. The monitoring of overall activities, decision points, causalities and interfaces was based on the treatment of 100 additional patients and on interviews with nurses and physicians. The project was closed with the identification of the three most critical process steps and modelling of the standard emergency care process in an event-process chain (EPC). RESULTS: The most time-crucial steps detected by the analysis were the process of developing a tentative diagnosis, including consultation and advice seeking by inexperienced physicians, the interface to imaging diagnostics and the search of hospital beds for inpatients. The results were visualized by standardized modelling of an event-process chain (EPC). CONCLUSION: The process analysis helped to identify inefficient process steps in the ED. Modelling with EPC is a useful tool to visualize and to understand the complexity of the emergency medical care and to identify key performance indicators for effective quality management.