Infection Prevention and Control

Problem Statement

Counties Manukau, in common with the rest of New Zealand, is experiencing a rapid increase in the number of cases of Carbapenemase-producing Enterobacteriaceae (CPE) detected.

What are we trying to achieve?

Our goal is to protect patients accessing services at CM Health from being colonised or infected by these organisms.

With the rapid importation of CPE organisms into the Counties Manukau area, from countries such as India and Fiji, the risk of exposure to these organisms increases, along with a related rise in the risk of severe morbidity.

This risk has an operational impact, through a rise in demand for single rooms and theatre delays. Our aim is to better this demand and improve identification of patients with CPE who are scheduled for theatre.

What have we done?

We have:

• increased our screening processes in clinical areas, in line with international recommendations related to control of CPE
• commenced surveillance of compliance with screening requests (for example, whether wards are doing patient screening, as requested by the Infection Prevention and Control team, or required the screening protocol); a sample screening compliance report is shown below
• included patient travel history in the screening requirements, in order to ascertain if the patient has travelled in high CPE risk areas, such as India
• provided support for CPE control in long-term care facilities, following an incident where a patient probably acquired CPE in a rest home
• increased the daily review of patients in isolation, and where appropriate the removal of warnings against their NHI records, to support the availability of isolation rooms
• updated our algorithms for defining CPE
• refined the Bioquell area decontamination algorithm, to enable efficient use of the resource
• designed a new process for cleaning and decontamination in ED, and started a trial to test it
• developed education materials and run sessions about CPE for front line healthcare workers
• attempted to rationalise the draft national guidelines for control of CPE; the draft guidelines were operationally difficult and did not address many issues, such as control within long-term care facilities
• modified theatre process to streamline management of CPE positive
• actively participated in the antimicrobial stewardship programme in CM Health.

The following image is of a sample screening surveillance report.

What did we find?

The rates of CPE continue to increase, especially in the community. Screening compliance has been patchy. Trends in CPE incidence will be shown through monthly reporting.

How did we make a difference?

To date, around 3000 NHI warnings have been removed.

An outbreak at the beginning of 2018 was successfully contained, as was an outbreak in the Transmission Risk Area in November 2018.

Due to the high rate of CPE importation into our area, it is difficult to assess the overall effect that our efforts are having on CPE carriage in CM Health. However, our efforts to protect patients from acquiring CPE will be ongoing and incremental.

Where to from here?

We will:

• establish a CPE infection prevention and control role or presence within primary care
• continue our surveillance of screening compliance within CM Health and provide feedback to the wards involved
• remain involved in developing the national guidelines
• reinforce the need for cleaning services to focus on cleaning and decontaminating rooms and the broader hospital environment to improve patient safety (rather than focusing on making the hospital look nice).