Collaboration in Action: How One Hospital Stopped a Neurosurgical Infection Outbreak

When a cluster of neurosurgical infections emerged at Advent Health Celebration in Celebration, Florida, swift collaboration between infection prevention and surgical teams became the key to containment—and long-term improvement. The facility faced an outbreak of Serratia marsescens linked to craniotomy procedures. Thanks to early recognition and a unique embedded role within the operating room (OR), the infection preventionist (IP) was able to respond in real-time, triggering a rapid system-wide response.

To learn more about the response, Infection Control Today® spoke with Charles Vickery, Jr, MSN, RN, CIC, CRCST, who is the infection prevention supervisor at AdventHealth Celebration, and Nicholas DeStefano, BSN, RN, CNOR, who is the senior nurse manager of the operating room at AdventHealth Celebration. The information was also given in a poster and a presentation at the Association for periOperative Registered Nurses Global Conference & Expo held in Boston, Massachusetts, from April 5 to 8, 2025.

“We did our poster and speech, called ‘Bacteria in the Brain: The Infection Preventionists’ Response.’ We chose this topic because we want to raise awareness of the need for collaboration inside and between departments,” Vickery, Jr, said.

Before the outbreak, the IP had already built strong relationships within the OR by shadowing surgeons, nurses, and support staff and gaining a firsthand understanding of workflows and surgical culture. This groundwork transformed what is often a tense, outsider role into one of trusted partnership. When the infections were identified, the infection prevention team did not need to push their way in—they were already part of the fabric.

A coordinated, cross-functional response involving neurosurgeons, anesthesia teams, surgical techs, nursing leadership, sterile processing, and hospital administration followed. A dedicated task force was created, protocols were reexamined, and process improvements were implemented across departments. Perhaps most significantly, the facility used this crisis to justify creating a formal infection prevention role focused on the OR, recognizing the value of proactive, embedded oversight.

The results speak volumes: no additional craniotomy infections have been reported since the outbreak in 2021. The team not only halted the outbreak but also laid the foundation for ongoing collaboration and safer surgical care.

“I think what was interesting about that collaboration piece is coming from the nursing aspect inside the room, and the team dynamic with physicians, anesthesia, and the surgical [technicians], and having an exterior [person] come in as an IP. You know what their role is, what they're doing in our OR as you [would] question anybody, and then how this changed over into now “He's helping us with something to save someone's life.’”

This experience demonstrates the power of early detection, interdisciplinary teamwork, and the importance of building bridges—not barriers—between departments. It also presents a model for other hospitals: directly integrating infection prevention into perioperative services can drive cultural change and clinical outcomes.