Leveraging the Electronic Medical Record to Identify Patients at Risk of Antibiotic Resistant Organisms

Abstract

Background: Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) pose a serious public health threat. The CDC guidelines for combating CP-CRE include a recommendation to screen selected high-risk patients. Objective: We describe a program to identify and screen patients at risk for CP-CRE. Setting: An academic, tertiary-care center with 1,297 licensed beds and 62,071 admissions per year. Methods: A report was created in the electronic medical record (EMR) to identify adult patients admitted in the previous 24 hours from countries and states with known CP-CRE transmission based on address and ZIP code. Patients with a known travel history outside the United States were also reviewed, but these data were inaccurate. Initially, a physician from Infection Prevention and Control (IPAC) placed orders for CP-CRE screening of these patients. Subsequently, a nursing protocol was developed to facilitate infection preventionists placing orders for CP-CRE screening earlier in the eligible patient’s hospital stay. An electronic communication is sent via the EMR alerting the patient care team to the order, the rationale for the order, and links to a tool kit with resources to help answer patient questions. A single perirectal swab is obtained by the nurse caring for the patient and is tested for Klebsiella pneumoniae carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), oxacillinase-48 (OXA-48), and Verona integron-encoded metallo-β-lactamase (VIM) by polymerase chain reaction (PCR). Results: From May 2018 to November 2019, 688 patients were screened for CP-CRE using the case-finding report and the nursing protocol. Overall, 9 patients with CP-CRE were identified: 1 KPC, 2 NDM, and 5 OXA-48, and 1 patient was identified to have both NDM and OXA-48. The yield of 1.3% from this screening is higher than that reported previously in the literature. Use of the nursing protocol has enabled IPAC to complete timely CP-CRE surveillance and prevent transmission to other patients. We are currently using a similar process to identify and screen persons at risk for the emerging infection Candida auris.Conclusions: The EMR can be leveraged for early identification and screening of patients with epidemiologically significant pathogens. Protocols within the EMR can be effectively replicated and modified to respond to emerging infections and changing surveillance guidelines.

Funding: None

Disclosures: Consulting fee-—Merck (Priya Sampathkumar)