Early identification and management of CPE risk in the Emergency Department.

Transcription

1 Early identification and management of CPE risk in the Emergency Department. Jo-Anne McShane 1, Andrew Maclean 1,2, Leanne Houston 4, Helen Marquand 4, Madeleine Smith 1,Mary O Reilly 1,2,3 Acknowledgements: Donna Cameron- Peter Doherty Institute, Sue Lloyd Jones- Eastern Health Pathology 1 Emergency Department, Box Hill Hospital, Eastern Health, Victoria, Australia 2 Eastern Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences Victoria, Australia 3 Department of Infectious Diseases, Eastern Health, Victoria Australia 4 Infection Prevention and Control, Eastern Health, Victoria Australia

2 Carbapenemaseproducing Enterobacteriaceae (CPE) Title slide Sub title and The lethal superbug

3 What is CPE? Gram-negative bacteria which have acquired the ability to produce enzymes that are resistant to the carbapenem class of antibiotics, considered the drugs of last resort for such infections. Enterobacteriaceae are a family of gram-negative bacilli that occur naturally in the gastro-intestinal tract. Large family of Gram-negative bacteria that includes: Citrobacter spp. Enterobacter spp. Escherichia spp. Morganella spp. Proteus spp. Salmonella spp. Serratia spp. Shigella spp. Klebsiella spp. Easily transferable to other species of bacteria

4 What s happening in Australia? n=29 N=2 other Total 440 n=0 n=14 n=116 n=143 n=17 n=116 n=3 Safetyandquality.gov.au CARAlert-Report-March-2016-to-March-2017.

5 Guidelines

6

7 ED presentations provide an opportunity for screening of potentially infectious patients and implementation of transmission based precautions (TBP).

8 April March ,491 ED presentations 7719 CPE CPE 2 Missed pts 8 IPAC Missed at triage- phone call by primary nurse to IPAC 1 Pathology-missed by ED =299 patients Excluded patients 18 excluded due to not having overseas hospital stay ie saw GP (n=12) or left immediately after triage (n=6),with 1 pt excluded as clearly stated in notes pt was screened and cleared previous admission. TOTAL: 281 patients

9 Tested in ED or ward? Emergency Department Ward Total Frequency Percent Not tested Total

10 Discharge outcome Frequency Percent Tested in ED Percent Tested on Ward Percent Not tested Percent Home Admitted % (total) 10% of admitted pts (total) 73% of admitted pts DNW Transferred to other hospital Total TOTAL TESTED

11 Tested in ED per month Total: 281 eligible patients, only 31 tested (9 tested on the ward).

12 Transmission based precautions CRE Frequency Percent tested for CPE in ED 11.74% of ED patients eligible for testing were tested Standard % (n= 195) were not Contact (non- CRE placed in correct TBP in related) ED!!!! Not filled out 'Nil' Other- cytotoxic, droplet Total

13 Audit identified issues Staff were not sure what tests to do No pathology forms Technology Communication -Triage nurses often picking up the risk but cubicle staff unaware of need to isolate and screen and CALD. Samples being sent to lab but not being processed. Why? Or not reported/or unable to access report on EMR Dr s not picking up CPE risk in notes Triage nurses often picking up the risk but cubicle staff unaware of need to isolate and screen. Went and had a look at what swabs we had- no red tops and 1 blue top Online pathology guide- incorrect. Alert system not clear Education- What is CPE?

14 Triage Case Study CPE risk Comments

15 1440- Be request- needs isolation and contact precautions (Dr) hrs 1511hrs

16 Remember to: Take travel history Assess risk factors Isolate with TBP- contact Screen

17 References Dolejska M, Masarikova M, Dobiasova H, Jamborova I, Karpiskova R, Literak I, et al. High prevalence of Salmonella and IMP-4-producing Enterobacteriaceae in the silver gull on Five Islands, Australia. Journal Of Antimicrobial Chemotherapy (JAC) [serial on the Internet]. (2016, Jan), [cited November 13, 2017]; 71(1): Abraham, S. et al. Isolation and plasmid characterization of carbapenemase (IMP-4) producing Salmonella enterica Typhimurium from cats. Sci. Rep. 6, 35527; doi: /srep35527 (2016). The sink as a potential source of transmission of carbapenemase-producing Enterobacteriaceae in the intensive care unit Kotsanas D, Wijesooriya WR, Korman TM, et al. Down the drain : Carbapenem-resistant bacteria in intensive care unit patients and handwashing sinks, Med J Australia, 2013, vol. 198 (pg ) Sidjabat, H. E., Townell, N., Nimmo, G. R., George, N. M., Robson, J., Vohra, R., Paterson, D. L. (2015). Dominance of IMP-4-Producing Enterobacter cloacae among Carbapenemase-Producing Enterobacteriaceae in Australia. Antimicrobial Agents and Chemotherapy, 59(7), Victorian guidelines on Carbapenemase- producing Enterobacteriaceae for health services version 2 April 2017 < Victorian guideline on carbapenemase-producing Enterobacteriaceae For health services December 2015 Department of Health Infection Prevention and Control of Carbapenem-resistant Enterobacteriaceae (CRE) in Western Australian Healthcare Facilities (Version 1), Healthcare Associated Infection Unit (HAIU), Communicable Disease Control Directorate, Department of Health, Western Australia. Carbapenemase producing Enterobacteriaceae in Australia Holding back the tide? Cheng, Allen C.Kwong, Jason C. et al. Infection, Disease & Health, Volume 22, Issue 4, Martin Cormican Emergency Triage Education Kit Poole K, George R, Shryane T, Shankar K, Cawthorne J, Worsley M, Savage N, Scott J, Welfare W. Evaluation of patient-held carbapenemaseproducing Enterobacteriaceae (CPE) alert card. Journal of Hospital Infection Jan 31;92(1): Hand Hygiene Australia