Infectious Disease and Immunology Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
Infection work rarely sits with one clinician. A fever in an older patient, a result that arrives after the shift changes, a bed that cannot be cleared for an isolation room, each of these moves through nurses, physicians, laboratory staff and administrators before anyone acts on it. The five cases below follow that path. Each describes a setting drawn from a fictional hospital network, sets out what the team knew and when, and asks where local protocols helped or fell short. Focus on the decisions and handoffs between people rather than a single correct answer.
Case Study 1
A slow overnight decline and a delayed call
Ridgeway Community Hospital, a 260-bed acute care hospital serving a mixed urban and rural catchment area.
The situation
Rosa, a 71-year-old retired teacher, was admitted to a general medical ward with a productive cough and fever. She was placed on the standard observation pathway, with vital signs recorded every four hours. Over the first evening her temperature edged upward, her heart rate climbed, and she grew drowsy between checks. The night charge nurse, Dev, recorded each set of observations, but the electronic record displayed the individual parameters without a running total. Two readings crossed the local escalation threshold before midnight. The covering hospitalist, Priya, was caring for a larger caseload in another wing and was reached by phone twice that evening.
The challenge
The team had to decide whether the pattern represented a deteriorating infection or a patient who was simply tired after a long day of tests. Priya needed a clear picture before deciding on investigations and whether to bring in the rapid response team. Dev was uneasy about calling the physician repeatedly without a clear threshold being met, and the local protocol gave both a score trigger and a clinical concern route. Nobody was certain which route applied.
Analysis
The most useful evidence in this case was the trend, not any single reading. A temperature that was only mildly raised, combined with a heart rate that rose over four checks and a new drowsiness, describes a patient whose reserve is shrinking. Rosa's needs were also social: she lived alone, had reduced mobility after a fall the previous month, and could not easily report change herself. An early warning score summed across parameters would have made the pattern visible at the bedside. The record should have shown the running total so that the trend was read as one picture rather than several separate numbers.
The local escalation protocol set a score trigger that required a senior review and an urgent call to the rapid response team, and it also allowed any nurse to escalate on clinical concern. Those two routes were written as parallel options, which in practice meant that each person assumed the other route had been considered. The hospitalist's advice by phone was framed around a single set of observations rather than the trajectory, so the escalation was postponed until the next scheduled check. A short structured call, using the protocol's own wording and the summed score, would have shifted the conversation from whether to worry to what to do next.
Actions taken
- Sum the early warning score automatically in the electronic view so that every set of observations shows a running total and the threshold status is visible at a glance.
- Rewrite the escalation protocol so the score trigger and the clinical concern route are sequenced, with the nurse calling the rapid response team first when either threshold is met and the physician informed afterward.
- Use a brief structured phone script for overnight physician calls that states the trend over the last three checks, the summed score, and the specific concern, and records the agreed next review time.
- Run a monthly review of overnight escalations on the ward, comparing time from threshold breach to senior review, and share the findings at the handover meeting for the nursing and medical teams.
Results
In the first full quarter after the changes, overnight escalations on the ward were made within the protocol window in 44 of 49 eligible events, compared with 27 of 46 in the quarter before. Median time from threshold breach to senior review fell from 52 minutes to 18 minutes. Rosa improved after senior review and was discharged home with a community follow-up plan. Her case became the teaching example at the handover meeting, mainly because the summed score had crossed the trigger two checks before the first call.
Questions for discussion
- Describe how a running total of the early warning score changes what a nurse notices by the third check after a rising trend.
- Explain how a team should weigh a clinical concern route against a score trigger when the two appear to point in different directions.
- Identify which information a covering physician needs on the phone to choose between further investigations and senior review, and who should supply it.
Case Study 2
A pending result lost between night and day shifts
Lakeview Regional Medical Center, a 380-bed teaching hospital with four medical wards and a shared infection prevention service.
The situation
On a 28-bed medical ward, a patient named Samuel, a 58-year-old warehouse supervisor, had been admitted with a suspected lower respiratory infection and was waiting on laboratory results. Two tests were still pending at the end of the night shift. The outgoing nurse, Hannah, wrote a handover note that listed his observations and fluid balance, then left the pending tests out of both the note and the verbal report because the day team was starting a busy round. The incoming nurse, Omar, read the note at the start of his shift and assumed the results had been reviewed overnight. Neither of them had checked the laboratory system, where one test had already returned a flagged result.
The challenge
The flagged result was not urgent in isolation, but it changed the infection control picture and the need for a follow-up conversation with the patient. The ward's handover standard required pending results to be read aloud, and the isolation status was supposed to appear in the verbal report. Neither element was confirmed at the bedside before the day round began. The team now had to find out how long the result had been waiting and who else might have acted on it.
Analysis
Samuel's needs depended on two pieces of information, and neither reached the day team as a usable fact. The result that had returned was a flag, and a flag without a named reviewer is easy to read as background noise. Bedside evidence, including a respiratory trend that had improved by morning, needed to be read alongside that result. Reviewing the test only in the laboratory system would have given the team a number, while the handover needed to give them a question to answer. Good handover treats each pending item as something with an owner and a deadline.
The ward's handover standard follows a structured template, and the failure occurred where the template depends on the speaker. Pending items were a required section, but nothing in the template prompted a check of the laboratory system, so a blank section could look the same as an empty one. Neither nurse was careless in a general sense. Each reasonably trusted the other's process, and the flagged result generated no alert that matched the handover checklist. A protocol that relies on a verbal summary to carry a written gap leaves the most important item to memory at the busiest point of the day.
- Assess the patient Confirm observations, pending tests, and isolation status before leaving the bedside.
- Verbal report Read pending and flagged items aloud with a named owner for each.
- Check and repeat Incoming nurse checks the laboratory system and repeats each item back to confirm.
- Audit and feedback Weekly sample review shares gaps with both teams and adjusts the template.
Actions taken
- Add a required check of the laboratory system to the handover template, so that every pending test is listed with its status and a named clinician responsible for reviewing it.
- Require the outgoing nurse to read aloud any pending or flagged result and the isolation status at the bedside, with the incoming nurse repeating each item back before the report closes.
- Set a measurable target that at least 95 percent of handovers on the ward include every pending result with an owner, verified through a weekly audit of ten handovers chosen at random.
- Pilot a bedside handover check where the incoming nurse verifies each pending result in the laboratory system, and track how many discrepancies it catches during the first month.
Results
After the template change and the bedside check were introduced, the ward audited 120 handovers in the following month. Pending results were recorded with an owner in 113 of them, compared with 71 of 118 in the month before the change. Discrepancies between the laboratory system and the verbal report fell from 9 to 2. Samuel's flagged result was reviewed by the day team before the morning round ended, and the follow-up conversation with him took place the same day. The bedside check added about four minutes per handover, a cost the ward accepted.
Questions for discussion
- Compare the written and verbal parts of a handover, and explain which carries greater risk when a pending item is left out of both.
- Describe what a bedside check should confirm, and name the team member who owns a result when the incoming nurse cannot reach the laboratory.
- Propose a way to measure whether a handover change improves safety without adding a burden that staff quietly work around.
Case Study 3
Isolation beds and staffing during a respiratory surge
Northfield Health System, a three-hospital network with 1,150 beds and a shared regional laboratory.
The situation
The network's largest hospital, Brookmere, had 34 single rooms suitable for isolating patients with suspected airborne infection, and during the peak of a respiratory season the number of patients needing one rose above that figure in a single week. Kwame, the bed manager, reported 41 patients waiting for an isolation room across the three hospitals, and 12 of them were already in general beds on wards without negative pressure. Two infection specialists were on call, and the nursing staffing pool had lost three experienced nurses to sickness that week. Elective admissions were scheduled to begin the following Monday, and the operations director, Ana, asked for options before the scheduling committee met.
The challenge
Ana needed a recommendation that would protect patients who required isolation without leaving general wards unsafe or cancelling care that could not safely wait. Each option moved the problem somewhere else. Opening a cohort area would expose staff and other patients, delaying elective cases would add pressure to emergency departments, and asking for more agency staff would not solve the isolation room shortage. The committee wanted the trade-offs described plainly, with the clinical risk of each choice stated.
Analysis
Teams grounded in Infectious Disease and Immunology tend to sort demand by clinical risk before they sort it by bed type, because the two are not the same. Among the 41 waiting patients, a larger group was stable and improving, while a smaller group was deteriorating and needed prompt assessment. The evidence available to the bed manager was a list of locations and arrival times rather than a severity grading, which meant the first task was to add a short clinical risk field to the waiting list. Without it, patients were prioritized by arrival time, and the people most likely to transmit or deteriorate were not reliably the ones moved first.
The network's isolation and surge plan assigns the bed manager to allocate rooms, the infection prevention lead to approve any cohorting, and the nursing director to release staff across sites, but the plan has no owner for the decision that joins them. In the third week of the surge, each leader made a sensible call: the bed manager held rooms for emergency admissions, the nursing pool was moved toward the highest-acuity wards, and elective lists stayed on the calendar. Those choices were reasonable in isolation and contradictory together. A joint daily huddle with a single written decision record would have made the trade-offs visible before they reached the wards.
Actions taken
- Add a clinical risk field to the isolation waiting list, scored at each bed review, so that rooms and staff go first to the patients who most need them.
- Create a single daily capacity huddle with the bed manager, infection prevention lead, nursing director and one surgical representative, and record each decision on a shared log.
- Stagger elective admissions by clinical priority over two weeks rather than canceling them in a block, and hold a small number of rooms for emergency isolation with a fixed release time.
- Set a staffing floor for each isolation ward so that no nurse caring for isolated patients is also assigned to more than one general ward during a shift.
Results
The committee adopted the staggered elective plan and the daily huddle, and it kept four rooms in reserve for emergency isolation throughout the surge. Within the first two weeks, 38 of the 41 waiting patients had an isolation room or a documented alternative within the target window, and no emergency admission was delayed for lack of a room. Two elective lists were moved, affecting 56 patients, and the network reported that staff overtime fell by roughly a fifth on the affected wards. Ward leaders cited the clinical risk field as the most useful change.
Questions for discussion
- Assess how a clinical risk field changes the order in which patients are moved, and what it cannot capture about transmission or deterioration.
- Explain why a daily huddle with a written decision record can prevent contradictory local decisions across several sites.
- Consider which staffing floor best protects isolated patients, and what the network would give up to keep it in place for a full season.
Case Study 4
Inconsistent infection outcomes across three wards
Brightwater Community Hospital, a 320-bed acute hospital with an active quality and safety committee.
The situation
Over a year and a half, the quality team at Brightwater observed that the rate of hospital-acquired infection varied widely across three medical wards that admitted similar patients. Ward C reported about twice the rate of Ward A, even though patient mix, average length of stay and nurse staffing looked broadly comparable on paper. Sunita, the quality lead, pulled anonymized indicators for each ward and each month, including isolation screening completion, time to culture review, and the proportion of discharges with written infection advice. The committee asked for a review that examined processes rather than individual staff.
The challenge
The quality team had indicators but not explanations. Ward C's higher rate could reflect screening that was missed, delays in reviewing cultures, differences in how infections were recorded, or a real difference in care. The team needed to separate recording artifacts from process failures before proposing changes, and it had to do so without slowing the work on the wards. Sunita also had only three months of data for the new screening step.
Analysis
The indicators pointed to a patient need that was not being met consistently: early identification of people who might carry resistant organisms, followed by clear communication of isolation requirements when they moved between wards. Clinical evidence in the case notes showed that screening was recorded for most admissions on Ward A and for fewer than half on Ward C, although the difference was not explained by admission volume. Patients transferred between wards during a stay were the most exposed, because a screening result on one ward did not reliably travel with them. The review therefore split the data by admission route and by transfer.
The hospital's infection prevention protocol assigns screening to admitting nurses, culture review to the physician, and transfer communication to the ward that sends the patient. Each step is sound on paper, but the protocol does not state who checks that a step has happened. On Ward C, the admitting nurses worked from a paper checklist that was not always scanned into the record, and the physicians often reviewed cultures during a morning round that the nurses did not attend. The result was partial handoffs, each defensible and none complete. Naming an owner for each checkpoint, and confirming that the owner can see the result, is the first repair.
Actions taken
- Agree a single data definition for each indicator across the three wards, including what counts as a completed screen and the time point at which a culture is considered reviewed.
- Move screening documentation into the electronic admission order set, so the screen is prompted at admission and the result appears on the ward board for the receiving team.
- Assign a named checkpoint owner for each transfer, and add a five-minute structured handoff at the morning round where nurses and physicians confirm open results together.
- Run a twelve-week plan, do, study, act cycle on Ward C, reviewing a control chart of the monthly rate and the screening completion rate every two weeks with the committee.
Results
Over the following quarter, screening completion on Ward C rose from under half of admissions to most of them, and the ward's monthly rate moved closer to that of Ward A, though it did not match it. Two of the three transfer checkpoints had named owners on nearly every case in the audit sample. The team judged part of the change to be a recording effect, since the scanned checklist had made earlier gaps visible, and said so in the report. The committee agreed to keep the indicator set unchanged for two more cycles before drawing firm conclusions.
Questions for discussion
- Examine how the three wards would compare if their indicator definitions had differed, and which comparison the committee would then have trusted.
- Describe a monitoring plan that would show whether an improvement held after the team stopped paying close attention.
- Evaluate whether a named owner for each checkpoint could create blind spots during periods when that person is absent.
Case Study 5
A partner's request during a notifiable infection review
Calder Valley Health, a regional network of two hospitals and a community outpatient clinic with a privacy office and ethics service.
The situation
Tomas, a 46-year-old electrician, was admitted to a medical ward with an infection that the public health service required the hospital to report. He was alert and able to make decisions, and he asked the team not to share his diagnosis with his employer or with his wife, Lena, who had phoned the ward twice to ask how he was. Lena had been in close contact with him at home. The discharge planner, Grace, needed to arrange follow-up that involved both the hospital and the community clinic. Tomas's wishes conflicted with the public health duty and with Lena's stated need for information about her own risk.
The challenge
The team had to decide what Tomas's confidentiality request could lawfully and ethically cover, what the public health duty required the hospital to share and by when, and how to talk with Lena without breaching either. Grace was concerned that a vague answer would leave Lena calling the ward again. The ethics service had not yet been asked to review the case.
Analysis
Tomas's capacity was not in question, and his preference deserved serious weight. A competent adult can usually decide who hears about his health, so the first task was to learn what he would share and with whom. The evidence was clear that the infection was notifiable and that close contacts could be at risk, but it did not show that Lena's need outweighed his confidentiality. Her needs were real, since she had questions about her own exposure and no named contact. The next step was a conversation that separated what the law required the hospital to pass on from what Tomas could keep private, and it needed a record.
Calder Valley's confidentiality policy allows disclosure without consent where a legal duty applies, but it requires the team to record the reason, limit the detail shared, and inform the patient where that is possible. The privacy office and the ethics service sit outside the ward, so the first difficulty was reaching them. Grace could not decide alone, and the ward nurse was unsure whether a phone answer to Lena counted as disclosure. Escalation should have gone to the privacy office and the infection prevention lead the same day, with the ethics service consulted on the decision about Lena's information. Written handoffs between these roles would have prevented that delay.
- 1Clarify patient wishesConfirm capacity and record what Tomas will share and with whom.
- 2Identify legal dutiesSeparate required reporting from information the patient can keep private.
- 3Escalate to privacy officeSame-day review of what can be shared, and with whom, before any call.
- 4Consult the ethics serviceReview the wider decision about Lena's information and her exposure questions.
- 5Document and informRecord the reason for each disclosure and tell Tomas what was shared.
Actions taken
- Confirm with Tomas, in private and with a clinician present, which details he is willing to share with Lena, his employer, and any other person, and record his answers exactly.
- Contact the privacy office and the infection prevention lead the same day to confirm which information the public health duty requires, the timeframe, and the minimum detail to be shared.
- Give Lena a clear, named contact and a short written explanation of her own follow-up options, without confirming Tomas's diagnosis or workplace details beyond what he has agreed, unless the privacy office advises otherwise.
- Refer the case to the ethics service for a documented consultation, and set a review point at the next multidisciplinary meeting so that the decision is revisited if Tomas's position changes.
Results
The privacy office confirmed the reporting duty within the day and agreed the minimum detail that could be shared with the public health service. Tomas accepted that the reporting would happen, and he agreed that Lena could be told he was being cared for and that she should seek her own advice about exposure. He did not agree to share his workplace details. The ethics service later reviewed the record and supported the approach. Lena received a named contact and called the ward once more, this time to arrange a follow-up.
Questions for discussion
- Assess how the team should separate a patient's confidentiality request from a legal reporting duty, and who should make the final decision.
- Compare a phone reply to a family member with a written explanation, and identify which carries more disclosure risk in this setting.
- Outline how the ethics service and the privacy office should share responsibility without each waiting for the other to act.
Learning Resources
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