Ms Denise Del Rosario-Kelly1, Ms Pauline Bass1, Ms Sue McLellan1, Ms Shirley Leong1, Associate Professor Andrew Stewardson1, Dr Rekha Pai Mangalore1, Dr Nenad Macesic1, Dr Sadid Khan1
1Alfred Health, Melbourne, Australia
Biography:
Denise Del Rosario-Kelly is a Senior Infection Prevention Nurse Consultant with over 20 years of nursing experience and postgraduate qualifications in neuroscience nursing and infection control. She’s currently completing a Master of Infectious Diseases Intelligence and brings a passion for innovative infection prevention education and data-driven approaches to outbreak management.
Abstract:
Problem/Issue Identified:
In December 2024, a measles exposure in our emergency department (ED) involved extensive patient, visitor, and staff follow-up. This high-consequence, low-frequency event exposed system vulnerabilities, including delayed case notifications and challenges in coordinating a rapidly evolving response. An incident debrief led to improvements that strengthened the Infection Prevention and Healthcare Epidemiology (IPHE) teams’ readiness amidst Victoria’s ongoing measles resurgence.
What Was Done to Rectify the Problem/Issue:
Initial measles exposure identification has been tightened through digital ED waiting room messaging to prompt early symptom disclosure, automated alerts sent to IPHE when a measles diagnostic test is ordered, and enhancing communication with our local Public Health Unit. Communication and coordination were strengthened by forwarding Department of Health (DH) alerts to ED leadership for wider dissemination. Process improvements included introducing stepped response guides, task delegation frameworks, and updated contact tracing templates and scripts. Centralised, accessible outbreak resources and facilitated contact tracing sessions with verified, functional links supported real-time coordinated actions.
The Results:
These changes have resulted in faster mobilisation of outbreak responses and increased team confidence, with system changes embedded as standard practice. No adverse outcomes from subsequent exposure events have occurred despite ongoing community transmission.
Conclusions:
This experience reinforced the value of evaluating our exposure and outbreak responses to generate lasting system improvements. The changes implemented continue to support outbreak readiness and provide a practical framework for managing future high-consequence infectious disease events.
Lessons Learnt:
Timely case notification, strengthened communication pathways, and accessible resources underpin sustainable and confident outbreak responses.