When a novel or targeted multi-drug resistant organism (MDRO) or resistance mechanism is identified, local public health must act quickly to prevent its spread, implementing CDC’s Containment Strategy. The Florida Department of Health in Orange County (DOH-Orange) found themselves in this exact situation at 4:00PM on the Friday before a holiday weekend, when they were notified of a patient in a local healthcare facility co-colonized with Verona integron-encoded metallo-ß-lactamase–producing carbapenem resistant Pseudomonas aeruginosa (VIM-CRPA) and Klebsiella pneumoniae carbapenemase-producing carbapenem-resistant Enterobacteriaceae (KPC-CRE).
They uncovered and investigated an outbreak, eventually ramping their efforts up to a regional level. Through this process, they developed a number of tools and resources to address gaps in healthcare personnel and patient education and to streamline processes. They have made these tools available in NACCHO’s toolbox. NACCHO spoke with Alvina Chu and Danielle Rankin from DOH-Orange about their containment response and the resources they developed.
Can you tell us a bit about the scale of your investigation?
Initially, we were notified of a novel MDRO—VIM-CRPA—found in a patient residing in an Orange County long term acute care hospital (LTACH). This was the first time in Florida that we had been notified of this organism producing VIM, necessitating an aggressive response. We found additional epidemiologically-linked cases, indicating an outbreak and transmission within this facility. Concurrently, we identified an ongoing KPC outbreak, signaling that infection control breaches were likely happening. Over the course of the outbreak we conducted 30 point prevalence surveys (PPS) (total 1,160 screenings), a full Infection Control Assessment and Response (ICAR) visit, direct observations, and environmental sampling. At the conclusion of the outbreak, DOH-Orange had identified 9 cases of VIM, 6 cases of VIM/KPC and 44 cases of KPC.
To understand the infiltration of these MDROs in our region and knowing these were likely not limited to one facility, we used a social network analysis to identify facilities at highest risk and initiated a regional response. In this regional response, DOH-Orange conducted 22 modified ICAR assessments; hand hygiene and personal protective equipment (PPE) audits; and supplementary PPS, screening 623 residents and identifying 5 additional VIM-CRPA and 7 KPC cases.
What resources did you develop to facilitate the PPS and patient screenings?
We both come from a lab background and know how frustrating it is having specimens rejected during an outbreak because they were improperly collected or shipped. CDC also wanted to ensure that process was standardized. Given that, we initially were very hands-on in trying to understand the process and where the facility may need additional guidance. We created a Facility Laboratory Collection Guidance outlining the type of PPE needed for specimen collection, supplies needed, and the process for collection. After the first PPS, we picked up and shipped the specimens every time to double check the requisition form and the specimens. This helped with data collection because we knew who was being screened and received the results directly so we did not have to piece things together afterwards.
For a containment response, it is important to get high collection rates to establish the incidence in a facility and determine if interventions are successful. At one point, only about 50% of the patients were being screened. We learned that direct care staff were being tasked with getting consent, and knowing they are often busy with caring for the patient, we came up with a template script and patient consent form to facilitate the process. The facility’s legal team reviewed it and we made sure the language indicated it was a public health outbreak response rather than a “study” or “research.” We worked to ensure that the script and the form were used consistently, at appropriate points during the patient’s stay, and discussed with the appropriate individuals (the patient or legal guardian), and that it was documented in the patient chart.
We also developed an MDRO Screening FAQ for patients and families (in English, Spanish, and Creole) to go along with that process. During an outbreak, the facility has an obligation to notify the patients and the FAQ ensured that patients could make an informed decision about whether to be screened.
You developed quite a bit of patient education materials and signage. How did you identify the need for these?
We developed several types of precaution signs: special contact precautions, droplet precautions, contact precautions, and airborne precautions. We were initially using other signage but found that it was not large enough, and people were going into rooms without seeing it, so we wanted to make it very obvious. We also wanted to clarify PPE and hand hygiene steps for visitors.
We created a patient and family guide to MDROs (available in English, Spanish, and Creole), because it was important for them to understand what an MDRO is. Patient’s family members may be afraid, particularly if they are required to wear PPE, so this helps to mitigate that fear and make sure visitors know how to protect themselves. We also wanted to make sure they do not contribute to the outbreak, for example by wearing gloves into the hallway or cafeteria.
You also put together a one-pager/fact sheet on antimicrobial stewardship programs. What prompted you to develop this resource?
We put together a one-pager/fact sheet on antimicrobial stewardship programs during the regional response when we realized that knowledge of stewardship programs was really lacking in some LTACHs and most nursing homes. We made this one-pager to provide them with resources. A lot of our patient education materials and the signage were developed when working with the first LTACH during the outbreak, but we realized that a lot of the barriers were the same in many facilities, so we were able to use those same materials and not recreate the wheel. This is valuable, since as a local health department you might be working on five different outbreaks simultaneously and you cannot spend 150% of your time on one response, like we needed to with this LTACH to address the infection control issues.
One other big gap that we noticed in many facilities we assessed was incomplete or inadequate environmental cleaning. That drove us to create a one-pager and checklist to help environmental services managers make their policies, streamline what they are teaching, and help the cleaning process go in the proper order.
What prompted the development of the Discharge Packet for Long Term Care Facilities?
We provide an epidemiology briefing to the chiefs of many emergency medical service agencies across Orange County at their monthly meeting. During this outbreak, they were made aware of the response from the start and were able to get their staff the proper PPE. They may go into a room without fully knowing why they have been called—they may know it is a stroke, but may not be told that the patient has an MDRO—and they wanted to know how to identify if a patient has this novel MDRO, so we created the transfer form to go on the front of the medical record whenever a facility calls for transport. This also led to more formal communications between the healthcare facilities as a patient was transferred, which we realized was not documented enough. So we expanded it to be a full transfer packet with additional information included.
You already shared a bit during NACCHO’s Webinar: Local Health Department Role in Containment of Novel Resistance, but what advice would you give to other local health departments facing a containment response?
When faced with a situation like this, plan your response as ongoing and far reaching. All of the tools we developed, even though they were specifically in response to an outbreak, are effective in containing essentially any new emerging infectious disease. Do not focus on the particular MDRO but consider an approach that is effective in containing anything that is new that might come your way (there will always be a new thing coming your way!). Plan for sustainability and fostering a culture change so that the effects are long lasting.