# A Structured Quality Improvement Framework for Managing Serratia marcescens Outbreaks in a Resource-Limited Neonatal Intensive Care Unit

## TL;DR

A structured quality improvement framework helped reduce Serratia marcescens outbreaks in a low-resource neonatal intensive care unit.

## Contribution

A PDSA-based framework for managing Serratia marcescens outbreaks in resource-limited NICUs is proposed and evaluated.

## Key findings

- Outbreak incidence decreased from 8.9 to 2.5 cases per 1,000 patient-days.
- Outbreak duration dropped from 53 to 14 days with the new framework.
- Hand-hygiene compliance improved from 78.9% to 92.0%.

## Abstract

Background: Neonatal intensive care units (NICUs) in resource-limited settings face major infection-control challenges due to patient vulnerability, high device use, and limited staffing. Serratia marcescens is a well-recognized cause of recurrent NICU outbreaks, however structured quality-improvement (QI) frameworks for outbreak management in low-resource settings remain insufficiently described.

Objective: To evaluate whether implementation of a structured, multimodal, Plan-Do-Study-Act (PDSA)-based QI framework was associated with improved outbreak containment and infection-control process measures in a resource-limited NICU.

Methods: We conducted a single-centre, retrospective pre-post quality improvement evaluation comparing two Serratia marcescens outbreaks (2022 and 2023) in the neonatal intensive care unit of Ibri Hospital, Oman. The 2023 event implemented a structured Plan-Do-Study-Act (PDSA) framework featuring early-warning triggers, multidisciplinary task-force activation, enhanced staffing, environmental decontamination, and real-time auditing. Primary outcomes were outbreak duration and incidence density (cases per 1,000 patient-days). Secondary measures included compliance with hand hygiene, personal protective equipment (PPE), and environmental hygiene.

Results: Outbreak incidence was observed to decrease from 8.9 to 2.5 cases per 1,000 patient-days, and outbreak duration was shorter, declining from 53 to 14 days. Hand-hygiene compliance improved from 78.9% to 92.0%, environmental-cleaning scores from 78% to 96%, and PPE compliance reached 100%.

Conclusion: Implementation of a structured, PDSA-based outbreak-management framework was temporally associated with improvements in infection-control process measures in a resource-limited NICU. Despite a limited sample size and an uncontrolled pre-post design, this model supports feasibility and measurable benefit in low-resource NICUs.