Practice Tip of the Week | From Compliance to Culture: What a CRAB Outbreak Taught Us

By Kerri Smith, RN, MSN, CIC

Every nurse has cared for a patient whose recovery depended not only on treatment, but on preventing the next infection. Infection prevention is introduced early in nursing education, yet healthcare-associated infections (HAIs) continue to occur despite policies, annual education, and routine audits. The challenge is rarely a lack of knowledge; it is sustaining consistent infection prevention practices at the bedside. 

A recent Carbapenem-resistant Acinetobacter baumanni (CRAB) outbreak investigation in a Texas burn intensive care unit illustrates this challenge. What initially appeared to be an isolated case quickly evolved into a cluster of infections. Despite established protocols, infection control assessments and response, ongoing education, and routine compliance monitoring, transmission of this multidrug-resistant organism (MDRO) persisted. 

The investigation highlighted an important reality: the gap was not what staff knew, but how consistently infection prevention practices were carried out in real time. 

Healthcare facilities across Texas face increasing pressure from HAIs, MDROs, evolving regulatory expectations, staffing shortages, and limited public health resources. As patient acuity rises and competing priorities grow, maintaining consistent infection prevention practices becomes increasingly difficult. These challenges underscore the need to move beyond education alone and adopt sustainable, system-level approaches that support frontline staff in delivering reliable care. 

A key turning point in the outbreak response was the implementation of adenosine triphosphate (ATP) testing to evaluate the effectiveness of environmental cleaning. ATP testing provided immediate, objective feedback, often identifying residual organic material on surfaces that appeared clean. Unlike traditional audit data that may not be viewed until days or weeks later, ATP results were available in real time, allowing staff to immediately connect daily practices with measurable outcomes. 

The immediate visibility of these results influenced behavior in ways traditional education alone could not. Rather than responding with additional education sessions, the team focused on building a culture of infection prevention, on which expectations were visible, embedded into daily workflows, and reinforced through shared accountability among nursing, environmental services (EVS), providers, and leadership. 

Three strategies helped drive this cultural shift:

Make infection prevention visible. 

Environmental cleaning results, high-touch surfaces, and infection risks were incorporated into daily huddles and unit discussion. Keeping infection prevention visible ensured it remained a consistent priority rather than an occasional focus. 

Leverage peer accountability

Unit-based champions and frontline staff reinforced best practices through real-time feedback and coaching in a multidisciplinary approach. Peer engagement fostered shared ownership and encouraged consonant adherence to infection prevention practices. 

Integrate prevention into routine care

Infection prevention practices were embedded into existing workflows, through interdisciplinary rounds, bedside shift reports, and unit specific collaboratively developed infection prevention protocols by incorporating these practices into routine care, adherence becomes dependent on memory and more consistent across the team. 

These interventions were not technologically advanced or resource intensive; they were intentional. ATP testing created a continuous feedback loop among nursing, EVS, providers, and leadership, linking daily actions to measurable outcomes and opportunities for improved cleaning techniques. More importantly, it helped staff recognize the direct connection between their everyday practices and patient safety. 

The most meaningful outcome was not improved environmental cleaning scores alone, but a measurable shift in awareness, accountability, and engagement. Infection Prevention became part of how care was delivered rather than another task to complete. As expectations become visible, reinforced by peers, and integrated into routine workflows, consistent practice became the norm instead of the exception. 

For Texas nurses, this approach offers a practical and scalable framework for infection prevention and control. Whether practicing in a large academic medical center or a small community hospital, the principles remain the same: make expectations visible, integrate them into everyday workflows, and reinforce them through peer engagement and accountability. These strategies require far fewer resources than responding to an outbreak, yet they have the potential to significantly reduce transmission risk before problems arise. 

Outbreaks rarely persist because policies are absent, they persist because practices are inconsistent. Education is essential, but education alone does not create reliability. When infection prevention is visible, embedded into daily workflows, and reinforced through peer engagement and accountability, it becomes part of the unit culture rather than another item on a checklist. Sustaining that culture, not simply increasing education, is what ultimately leads to safer care for patients, staff, and communities. 

References

Centers for Disease Control and Prevention. (2024). Healthcare-associated infections (HAIs). https://www.cdc.gov/hai

Centers for Disease Control and Prevention. (2023). Guidelines for environmental infection control in health-care facilities. https://www.cdc.gov/infectioncontrol/guidelines/environmental

Donskey, C. J. (2013). Does improving surface cleaning and disinfection reduce health care–associated infections? American Journal of Infection Control, 41(5 Suppl), S12–S19. https://doi.org/10.1016/j.ajic.2012.12.010

Guh, A. Y., & Bulens, S. N. (2021). Epidemiology of carbapenem-resistant Acinetobacter baumannii in healthcare settings. Clinical Infectious Diseases, 73(Supplement_1), S8–S14. https://doi.org/10.1093/cid/ciab101

Weber, D. J., Anderson, D., & Rutala, W. A. (2013). The role of the surface environment in healthcare-associated infections. Current Opinion in Infectious Diseases, 26(4), 338–344. https://doi.org/10.1097/QCO.0b013e3283630f04

World Health Organization. (2022). Infection prevention and control. https://www.who.int/health-topics/infection-prevention-and-control