Screening for carbapenemase-producing enterobacterales (CPE) and isolation in single rooms while awaiting test results is recommended for hospitalised patients who are at risk of CPE carriage.1,2 However, single rooms are limited in hospitals and isolation can adversely impact on patients. This project studied the effect of a rapid CPE test on reducing the time that patients are unnecessarily placed in isolation pending screening results.
Aim
To reduce the number of days that patients admitted through the emergency department (ED) and screened for CPE remain in isolation unnecessarily by 50% within 12 months.
Benefits
For patients
- Decrease unnecessary time in isolation pending results of CPE screening.
- Decrease in adverse events associated with isolation, e.g. less interaction with staff, delays in investigations or procedures and stigma.
For staff
- Decrease in time patients are in isolation translates to a decrease in overall time that staff spend putting on and removing personal protective equipment, such as gowns and gloves, while patients are in isolation.
For the healthcare system
- More appropriate use of limited single rooms with resulting improvement in patient flow through the emergency department, wards and intensive care unit.
- Decrease costs associated with isolation, such as for personal protective equipment, additional time in hospital due to increased length of stay and additional time in the intensive care unit while waiting for the availability of an isolation room.
Background
CPE are multi-drug resistant bacteria which are an increasing global health threat. To reduce the spread of CPE in hospitals, state and national guidelines recommend early identification of individuals with CPE by performing a screening test on patients if they are at risk of carrying the bacteria (such as those who have received healthcare contact overseas).1,2 These patients are isolated in single rooms and placed on contact precautions (staff wear gowns and gloves when caring for them) in hospital until the results of the screening test are available.
At Royal Prince Alfred Hospital, the majority of patients who are tested are negative for CPE, so they are placed in isolation unnecessarily pending the results of screening. This can be problematic as isolation rooms are limited in hospitals and this can affect the flow of patients through the emergency department, wards and the intensive care unit. In addition, patients in isolation may experience adverse events such as less contact with healthcare workers, delays in investigations for their medical condition and stigma.
The current testing for CPE screening at Royal Prince Alfred Hospital takes 48 hours before a negative result can be issued. A more rapid test will reduce the time to finalise results, and could allow patients who are not CPE carriers to be released from isolation earlier.
Implementation
This project was conducted at Royal Prince Alfred Hospital over six months.
Patients were included in the study if they were at risk of being CPE carriers based on national and local guidelines, including having had healthcare contact overseas in the last 12 months.
Two methods for CPE screening in this patient group were compared, being assessing chromagar culture versus a polymerase chain reaction (PCR) directly from swabs.
The below information was collected over a period of six months for both screening methods:
- the time taken for test results to become available
- the results of testing.
Unnecessary days in isolation for CPE negative patients and overall testing costs were estimated over a 12-month period for varying levels of CPE in the population of patients screened.
Status
Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.
Dates
Samples and data were collected during two three-month periods between September to November 2018 and June to September 2019.
Implementation sites
Departments of Microbiology and Emergency, Royal Prince Alfred Hospital, Sydney Local Health District.
Partnerships
NSW Health Pathology
Results
- The median time to obtain a screening result by using the culture test was 46 hours versus seven hours for the direct PCR test.
- Overall, 91% of patients who were screened did not require isolation.
- CPE negative patients spent on average 39 excess hours unnecessarily isolated for culture versus direct PCR screening, with the median number of hours being 38.
- If 2% of patients tested are CPE carriers, the average additional cost for PCR testing for every day of isolation avoided was estimated to be $54. This estimate was $53 if the testing was done in a group where 50% of patients tested are CPE carriers. Although direct PCR testing has high initial cost, the additional cost per day in isolation avoided is modest.
- A rapid test for CPE screening facilitates judicious use of limited isolation rooms and has the potential to improve patient flow through the hospital.
Lessons learnt
- Implementation of this project required the collaboration of a number of departments within the hospital, including the microbiology laboratory, ED staff, infection control personnel and members of the executive.
- Good communication and education of staff was required regarding differences in testing requirements, for example the collection of a different type of swab.
- There were challenges in obtaining rapid results for tests on weekends and after hours given the limited staff resources in the laboratory during these times.
References
- NSW Ministry of Health. Surveillance & Response for Carbapenemase-Producing Enterobacterales (CPE) in NSW Health Facilities GL2019_012. Sydney: NSW Ministry of Health; 2019.
- Australian Commission on Safety and Quality in Health Care. Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE). A guide for acute care health facilities. Sydney: ACSQHC, 2017.
Contact
Dr Andie Lee
Senior Staff Specialist in Infectious Diseases and Microbiology
Royal Prince Alfred Hospital
Sydney Local Health District
Phone: (02) 9515 5026
Email: andie.lee@health.nsw.gov.au
