Considering the burden of enhanced CRE screening

swabs

The recent PHE CPE toolkit advocates implementing targeted screening and isolation of carriers. Reading the guidelines in a little more detail, the ‘triggers’ for screening a patient for CPE are, in the last 12 months: (a) an inpatient in a hospital abroad or (b) an inpatient in a UK hospital which has problems with spread of CPE (if known) or (c) a ‘previously’ positive case. Patients who screen positive should be placed in contact isolation; patients who screen negative should be placed in contact isolation until a further two consecutive negative screens have been taken. It’s important to note that the negative screens must be at least 48 hours apart. So, for patient who turns out to be negative will be in contact isolation for around 6 days (screens collection on days 0, 2 and 4, and a further day for the final negative screen result).

The number of patients who will meet the trigger for screening is currently unknown, but I have heard whispers of 25-50% of all admissions. This will place a considerable burden on already over-stretched isolation facilities, and bear substantial cost implications.

Single rooms in the NHS are already in very short supply. Indeed, recent press and commentary highlights the implications of running out of single rooms: patients shunted around “like parcels” in the middle of the night to relieve bed pressures.

Now, you could argue that patients who screen negative for CPE but are awaiting their confirmatory negative screens do not need to be isolated in a single room; they can be isolated in a bay. But if 25-50% of patients suddenly begin contact precautions, you’d quickly run into problems. Patients on contact precautions take longer to care for, and tend to get less attention than other patients resulting in more adverse events, as illustrated by a couple of recent Controversies blogs. Also, I fear you may begin to see ‘isolation fatigue’, where the procedure loses its impact if it has to be applied so broadly. And then there’s the cost. A recent US study calculated that contact precautions cost around £23 ($35) per patient day (not including the cost of disposal for all that additional waste!). If 25% of the 100,000 patients admitted to a London hospital Trust met the trigger for CPE screening and turned out to be negative, the price tag for isolation alone would be pushing £3.5m.

I support the PHE guidelines and agree that we need to “search and destroy” CPE above all else before it becomes endemic. However, are they feasible to implement in their current form?

Image: ‘Swabs’ by Frank Carey.

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5 thoughts on “Considering the burden of enhanced CRE screening

  1. Well written synopsis and analysis of burden to CP. It’s getting more common to hear these conversations about challenges of additional precautions. With more super bugs surfacing is there value in exploring other broader interventions that might minimize precautions. Thinking of partitions in ward rooms or other more economical dividers?

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    • There does seem to be a bit of a backlash against CP at the moment. There’s a couple of options for temporary or semi-permanent segregation of multi-occupancy bays into single occupancy pods. However, even if you do this, you still need to apply CP: in fact, much of the backlash over CP is coming from the US, which is more or less 100% single rooms. CP have pros and cons but the pros outweigh the cons for me if used rationally.

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  2. Truly, this problem is complex on so many levels. I wonder if we are approaching a day in which hospitals will have to deem entire buildings/wings as “isolation” areas. It truly seems that day is upon us and makes one scratch their head at the latest on MDROs!

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  3. Good Morning, Thank all of you for your discussion, Gwen.Borlaug@wi.gov, CIC MPH WS DPH is our States Nurse Leader in MDRO-CRE education and reporting. Wisconsin DPH has all the resources you need to educate and surveillance for CRE. My facility has implemented the intra facility transfer form and we are at 100% compliance at admission, and developing policies for use in admission and discharge from Hospital units and Residential units. Call Gwen 608-267-7711 or e-mail me and I can forward all the Wisconsin CRE programs. This is a helpful and wonderful educational experience. tstevens@lakeview.ws

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