I led a workshop at IPS today with my colleague Tracey Galletly on using PHE’s Toolkit to build a CPE policy. We based the session around a series of multiple choice questions that the audience voted on. I thought I’d share the results and key points raised!
We began with a quick introduction to CPE, outlining some European, UK, and local context (you can download the slides here). You can download the results of the multiple choice questions here (n=26).
The Toolkit recommends risk-factor based screening of all admissions, with no mention of universal screening in high risk specialties, such as ICU. I think this is a mistake and the best approach is a mixture of universal screening of high-risk specialties, plus risk-factor based screening of all other admissions – and the delegates agreed, in the main!
I was surprised to see that the majority of delegates advocated three screens each separated by 48 hours with preemptive isolation whilst awaiting the results, as recommended in the Toolkit. We quickly recognised that this is not feasible given the amount of CPE screening we do, and have some data that a single screen is as sensitive as multiple screens for detecting CPE carriage, so have gone down a road of a single screen without preemptive isolation.
The majority of delegates recommended contact precautions using gloves and aprons, although some favoured gowns. A couple of respondents chose to include masks in the PPE set, but this was only in the case of respiratory CPE infections. Nobody was willing to fess-up about recommending no PPE at all…
Nobody agreed with the Toolkit recommendation to make no change to cleaning and disinfection for terminal disinfection following a case of CPE. There was an even split between those recommending sodium hypochlorite and HPV, with most others making context-dependent disinfection recommendations.
Finally, the Pandora’s Box that is staff screening! Around half of the audience thought we should never do it (in line with the PHE Toolkit), and most of the rest, that staff screening should only be done during ongoing outbreaks. The key issue with staff screening for CPE is what do you do with a staff carrier? With MRSA, at least you could attempt decolonisation. In the case of CPE, we don’t have that option, so the only useful action would be to remove the colonised staff member from the front line if they were felt to be perpetuating an outbreak. Not an easy discussion to have, should the situation arise in your hospital. But is it really better not to know?
The sample size was small, and I am sure this survey does not accurately represent the ‘NHS view’ – but it does reinforce my feeling that the PHE Toolkit needs to be revised in terms of who to screen, when to screen them, how to manage the contaminated environment, and perhaps staff screening during protracted outbreaks.