Combating Carbapenem-Resistant Organisms in Neurosurgery: A Multidisciplinary Bundle-Based Approach

A Multidisciplinary Bundle-Based Approach

Purpose: Carbapenem-resistant organisms (CROs) have been listed as the primary risk resistance bacteria due to their high detection rates and extensive drug resistance. Research on the effectiveness of CRO intervention programs in secondary hospitals is limited. This study aims to observe the effect of multidisciplinary-based and bundle interventions under PDCA (plan-do-check-act) cycle management on the control of CROs in neurosurgery.

Patients and Methods: We conducted a before-after study from January 2021 to December 2023, which was divided into pre-intervention phase and intervention phase. The surveillance analysis and event analysis were used to identify the key links and targeted pathogens of the intervention. PDCA cycle management tool was used to strengthen the bundle management of multidisciplinary collaboration. After one year of PDCA intervention, the process surveillance and outcome surveillance indicators of prevention and control measures from January 2023 to December 2023 were collected and compared with the pre-intervention phase (January 2021-December 2022).

Results: A total of 1809 patients were involved in our study. The 11 prevention and control measures were evaluated. After the implementation of PDCA cycle management, the measures including timely completion of multi-drug resistance prevention and control registration, and issuance of contact precaution orders, were significantly improved (p < 0 xss=removed xss=removed>

Conclusion: The multidisciplinary and bundle interventions based on PDCA cycle management tool had a good effect on the prevention and control of CROs in neurosurgery.

Keywords: PDCA, carbapenem-resistant organisms, neurosurgery, intervention

Introduction

The rapid spread of multidrug-resistant organisms (MDROs) in hospitals has become a global public health threat. At present, the drug resistance problem in China is more serious than that in some developed countries. Among them, the most attention needs to be paid to carbapenem-resistant organisms (CROs), which have been listed as the primary risk resistance bacteria of WHO due to its high detection rate and extensive drug resistance. It mainly includes carbapenem-resistant Enterobacterales (CRE), carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA). Carbapenem-resistant Klebsiella pneumonia (CRKP) and carbapenem-resistant Escherichia coli (CREC) were the main CRE. CROs are among the most challenging antibiotic-resistant pathogens to emerge in the clinical setting. They spread rapidly in healthcare environments and can lead to significant outbreaks by contaminating the environment, equipment, and hands, particularly in institutions with limited infection prevention and control (IPC) resources.4,Their extensive or pan-drug resistance results in very limited therapeutic options, causing high mortality rates in infected patients. A meta-analysis suggested that mortality was significantly higher in CRKP patients (466/1093, 42.6%) than in those with carbapenem-susceptible Klebsiella pneumoniae (231/859, 26.9%). Other studies have reported that the all-cause mortality rate for patients infected with CRE reaches 50%, whereas the mortality rate for patients with CRO blood infections was as high as 56.3%, and 76.6%.

As medical science continues to make breakthroughs in extending human longevity, the aging of Shanghai’s population is becoming increasingly prominent. Within the city’s current three-tier healthcare system, secondary hospitals primarily treat elderly individuals with complex underlying diseases, frequent hospitalizations, transfers between various healthcare institutions, long-term exposure to antibiotics, and invasive procedures, thus becoming a high-risk group for CRO infection or colonization. The results of the previous infection control professional (ICP) surveillance work revealed that the detection rates for CRKP and CREC at the hospital in 2021 surpassed those reported by CHINET (China Antimicrobial Surveillance Network) (CRKP: 42.24% vs 24.4%, CREC: 5.30% vs 2.0%). Consequently, it is imperative to implement effective interventions to control CROs in this category of hospitals. CRO infection prevention and control is complex and involves multiple disciplines and departments. Thus, it is difficult to achieve control with one single intervention strategy. Current CRO intervention studies were adopting a bundle strategy. For instance, in epidemic settings, hand hygiene, contact precautions, active screening, isolation and environmental cleaning are strongly recommended for all CROs, and education, timely notification, communication, antimicrobial stewardship, active surveillance are recommended in CDC CRE toolkit. Previous studies have confirmed that the bundled management of multidisciplinary collaboration has a positive practical effect on the prevention of MDROs infection in hospitals. There were some differences in the intervention combination elements selected by each institution based on their actual situations.

In recent years, studies on MDROs prevention and control interventions have involved a variety of management tools, including PDCA cycle management. PDCA cycle management method includes four steps: Plan, Do, Check, and Act. The management tool has been widely used in the medical field.20 Some studies have shown that the management method can effectively reduce the incidence of nosocomial infection and improve the ability of medical quality management.21–25 A recent meta-analysis by Chinese scholars indicated that the majority of intervention studies involving CROs in China were conducted in large tertiary hospitals (20/21, 95.2%), with few related studies reported in secondary hospitals.26 Building upon the data from our previous research, we conducted a problem-oriented prevention and control practice based on PDCA cycle management in neurosurgery at a secondary hospital in Shanghai,China.

Patients and Methods

Study Design

The study was conducted in neurosurgery of Shidong Hospital, a secondary general teaching hospital located in Shanghai, China. The neurosurgery department owned 5 rooms, 20 beds, 4 clinicians and permanent nursing staff. The hospital has a dedicated IPC team with a stable staff composition. The study was divided into 2 phases: pre-intervention phase, from January 2021 to December 2022, and intervention phase, from January 2023 to December 2023. During the pre-intervention phase, we performed proactive and prospective surveillance, and investigated a suspected outbreak of CRKP infection occurred in neurosurgery in December 2021. During the intervention phase, we implemented a multidisciplinary-based and bundle intervention by the PDCA cycle management.

Subjects

We included all patients admitted to the neurosurgery between January 2021 and December 2023. Patient data were collected from electronic medical records. In the clinical microbiology laboratory, species were identified using the automated VITEK 2 system (bioMérieux, Marcy l’Etoile, France). The antimicrobial susceptibility testing was also determined by VITEK 2 and breakpoints were applied according to the Clinical and Laboratory Standards Institute (CLSI).28 The patients colonized or infected with CRO strains were as the objects of supervision. The duplicate strains and contaminated strains were removed. The privacy of all patients was fully protected and informed consent was waived. This study was approved by the ethical committee of Shidong Hospital (2023–057-01).

PDCA Details 

Plan

Analyze the Current Situation and Find Out the Problems

According to the surveillance statistics of ICP, the detection rates of CRAB, CRKP and CRPA were high in the hospital in 2021, and the neurosurgery was with the highest detection rate. Among them, the detection rates of CRAB, CRKP and CRPA were significantly higher than that of the hospital (p < 0>

Analyze the Influencing Factors Through Investigation of a Suspected Outbreak of CRKP Infection

A suspected outbreak of CRKP infection occurred in neurosurgery in December 2021.27 The investigating analysis found that the suspected outbreak was closely related to the sink in the ward bathroom, possibly due to the environmental contamination of pathogens in patients with CRKP infection/colonization and the hand transmission by medical staffs, caregivers and accompanying family members. The deep causes of high detection rate of CROs in the neurosurgery were analyzed by fishbone diagram.