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How San Quentin’s medical team overcame an explosive Legionnaires’ outbreak

The disease could have been deadly to the 5,400 inmates and staff if not for the actions of the facility’s primary care providers


The medical professionals made the difficult but necessary decision to temporarily turn off the water at San Quentin and proceed with the investigation that resulted in discovering the source of the exposure, the cooling towers. The investigation led to the development of new maintenance protocol for use statewide.

Photo/San Quentin State Prison

By Krissi Khokhobashvili and Liz Gransee

Reprinted with permission from Inside CDCR.

In September 2015, San Quentin State Prison experienced an explosive outbreak of Legionnaires’ disease. The disease could have been deadly to the 5,400 inmates and staff if not for the actions of the facility’s primary care providers.

Within minutes of noticing a marked increase in pneumonia cases among patients, the team members were exchanging thoughts about their clinical suspicions. They immediately researched possible causes, established a working diagnosis, set parameters for treatment and began aggressively treating patients with antibiotics to halt potential exposure.

The providers contained the outbreak, saving patients and staff lives. In addition to being named Healthcare Professional of the Year, the team also received a Unit Citation, recognizing great courage displayed by a departmental unit in the face of immediate life-threatening circumstances.

In this Q&A, Dr. Elena Tootell, chief medical executive at San Quentin, discusses the importance of cohesive teamwork, effective decision-making and cross-agency communication.

What are you most proud of in regard to the response to the Legionnaires’ outbreak?

I am proud of how the medical, healthcare and institutional community came together. Everyone worked hard, agreeing to work early, late and on weekends to ensure the patients were safe.

Legionnaires’ disease is a serious illness and we would have expected several fatalities in an outbreak of this size. This did not happen because of the immediate and overwhelming response of the entire team.

What sort of preparation and training go into being ready for such an event?

We have excellent medical providers at San Quentin and when the presentation of several cases of pneumonia appeared unusual, the providers worked together to rapidly consider the possibilities, establish a plan and implement it effectively.

Because of the teamwork and communication between the medical providers, we were able to identify the Legionella outbreak early and get the water and air-conditioning units turned off quickly.

The most significant part of the preparation for this event was developing the medical providers into an effective team. Each of the providers respects each other and asks for assistance when they need help caring for a patient.

What is a “typical” day like in San Quentin healthcare, and how does that change during an event like this one?

A typical day is similar to any medical office. The providers have a schedule of patients they see them for chronic conditions or new complaints.

When we identified the Legionella case, the medical department changed the schedule in order to focus all efforts on treatment and surveillance. We pulled patient and medication lists to identify those most at risk of death, we had nurses walking the units and sending patients to clinic.

During the Legionella outbreak, most of the work was to care for and identify the patients with Legionella.

San Quentin is a unique place. What is the secret to the healthcare staff, custody staff, executive management and inmates working so well together?

One of the things about the San Quentin community that made the response to this outbreak so effective is the open communication between all parties.

It began with a provider group that, even under normal circumstances, is always sharing questions, concerns and even jokes with each other via email. This produced a rapid exchange of views, as the possibility of an outbreak became a topic.

Then public health nursing and subsequently the entire nursing department were able to be rapidly involved in the surveillance and treatment.

Custody met frequently with all parties and gave feedback both on individual inmates with problems, as well as on larger-scale issues related to the response to the outbreak.

All parties met with inmates singly and in groups to ensure they understood what was happening and why and were able to respond to questions and concerns as they came up.

This multi-directional and ongoing communication prevented panic, facilitated the response and enabled all concerned to tolerate the multiple adverse impacts, as well as focus the efforts of the entire institution on minimizing harm and ending the outbreak.

About the authors
Krissi Khokhobashvili is public information officer II for CDCR Office of Public and Employee Communications.

Liz Gransee is public information officer II for California Correctional Health Care Services.