Pilot Testing of an Out-of-Country Medical Care Questionnaire with Screening and Cost Analysis of Pre-emptive Isolation for Carbapenem-resistant

Enterobacteriaceae in a Large Canadian Health Region Nipunie Rajapakse1, Joseph Vayalumkal1,2, Debbie Lam-Li2, Craig Pearce2, Gwynne Rees2, Linda Kamhuka2, Gisele Peirano3, Corrinne Pidhorney2, Donna

Ledgerwood2, Nancy Alfieri2, Karen Hope2, Dan Gregson3,4, Johann Pitout3, Thomas Louie 2,4, John Conly2,3,4 1Department  of  Pediatrics,  Alberta  Children’s  Hospital,  Calgary,  Alberta,  Canada  2Infec=on  Preven=on  and  Control,  Alberta  Health  Services  –  Calgary  Zone,  Calgary,  Alberta,  Canada    3Calgary  Lab  Services,  Calgary,  Alberta,  Canada  4Department  of  Medicine,  

University  of  Calgary,  Calgary,  Alberta,  Canada    

SUMMARY •  An out-of-country medical care (OCMC) questionnaire was used to detect patients

requiring screening for carbapenem-resistant Enterobacteriaceae (CRE). •  No patients were found to be colonized with CRE. •  Cost: 3 days of pre-emptive isolation for all recipients of OCMC in the previous 12

months (extrapolated 3.1% of admissions) = additional $2 380 025 per year.

OBJECTIVES •  Determine the proportion of admitted patients who received any type of OCMC in the

previous 12 months •  Assess the CRE colonization status of patients who received OCMC •  Estimate the costs associated with a pre-emptive isolation strategy for these patients

BACKGROUND The spread of CRE has become an important global public health concern. A key risk factor for CRE acquisition is the receipt of medical care in countries considered endemic for CRE.1 Prompt identification and isolation of patients infected or colonized with CRE has been advocated to prevent transmission in hospital settings but carries significant resource implications.

METHODS •  Focused OCMC questionnaire piloted at four tertiary care

hospitals (July - August 2012) •  Questionnaire administered to all patients at the time of hospital

admission by nurse/clerk •  Patients with any OCMC within 12 months (regardless of

location) screened for CRE by rectal swab/stool sample using KPC CHROMagar™ media (CHROMagarTM, Paris, France)

•  Costs for pre-emptive isolation extrapolated from published data

on isolation costs for extended spectrum B-lactamase-producing gram negative organisms2.

•  Inflation adjusted (Bank of Canada3) cost analysis for 3 days of: •  Use of a private room •  Contact precautions (including additional nursing time

and supplies) •  Infection Control and Housekeeping time

 

REFERENCES  1.  Brink  A,  Coetzee  J,  Clay  C,  et  al.  The  spread  of  carbapenem-­‐resistant  Enterobacteriaceae  in  South  Africa:  Risk  factors  for  acquisi=on  and  preven=on.  S  Afr  Med  J  2012;102(7):599-­‐601.  2.  Conterno  LO,  Shymanski  J,  Ramotar  K,  Toye  B,  Zvonar  R,  Roth  V.  Impact  and  cost  of  infec=on  control  measures  to  reduce  nosocomial  transmission  of  extended  spectrum  B-­‐lactamase-­‐producing  organisms  in  a  non-­‐outbreak  sebng.    J  

Hosp  Inf    2007;65:354-­‐360.  3.  Bank  of  Canada  Infla=on  Calculator.  Bank  of  Canada  website.  hep://www.bankofcanada.ca/rates/related/infla=on-­‐calculator/.  Accessed  April  28,  2013.    

CONCLUSIONS •  Pre-emptive isolation based on a history of OCMC alone is not economically

practical at this time given the low prevalence of CRE colonization in OCMC recipients in our setting.

•  Ongoing surveillance and stringent infection control practices will be critical for identifying and limiting the spread of CRE amongst hospitalized patients in Canada.

RESULTS

206  received  OCMC  

121  received  Outpa3ent  Medical  

Care  (59%)  

37  received  Inpa3ent  Medical  Care  (18%)  

33  received  Outpa3ent  and  Inpa3ent  Medical  

Care  (16%)    

15  pa3ents  had  unspecified  type  of  

care  (7%)  

13  835  admissions  

6646  administered  screening  

ques3onnaires  (48%)  

206  received  OCMC  (3.1%)  

101  pa3ents  screened  for  CRE  (49%)  

No  pa3ents  found  to  be  

CRE  colonized  

105  pa3ents  not  screened  for  CRE  (51%)  6440  had  not  

received  OCMC  (96.9%)  

7189  not  administered  screening  

ques3onnaires  (52%)  

83  010  admissions  per  year  

2573  Inpa3ent  

and  Outpa3ent  OCMC  

recipients    each  year  (3.1  %  of  

admissions)  

$797  per  pt  for  3  days  isola3on  

Private  Room:  $600  

Contact  Precau3ons:  $165  Infec3on  Control  

3me:  $10  Housekeeping  3me:  $22  

1.16  infla3on  

factor  from  2005  to  2013  

$2  380  025  per  year  

Figure  1.  Admission  Screening  Ques3onnaire  

United  States  34%  

Asia  23%  

Europe  15%  

Central/  South  America  

11%  

Other  17%  

Figure  3.  Loca3on  of  Out  of  Country  Medical  Care  

Figure  2.  Breakdown  of  pa3ents  screened  and  type    of  Out  of  Country  Medical  Care  received  

Figure  4.  Cost  analysis  of  3  day  pre-­‐emp3ve  isola3on  strategy    

•  2 month study period = 13 835 admissions.

•  Screening questionnaires administered to 6646 patients (48% of all admissions).

•  206/6646 (3.1%) were found to have received OCMC.

•  CRE screening samples obtained for 101 patients (49%).

•  No patients were colonized with CRE. •  Outpatient visits comprised 59%,

inpatient hospitalizations 18%, and both types of care 16%.

•  Most common locations for OCMC were

the United States (34%), Asia (23%), Europe (15%) and Central/South America (11%)

•  Extrapolation to a full year yielded 2573

OCMC recipients requiring pre-emptive isolation at an additional cost of $2 380 025 per year ($925/patient isolated).

•  The additional cost of isolating only recipients of inpatient OCMC would be $809 375/year.

Dr.  Nipunie  Rajapakse  Pediatric  Infec3ous  Diseases  Clinic  Alberta  Children’s  Hospital    2888  Shaganappi  Trail  NW  Calgary,  Alberta    T3B  6A8  Ph:  (403)955-­‐2200    Fax:  (403)955-­‐2853  nipunie.rajapakse@gmail.com