Assessment of public health perspectives on responding to an emerging pathogen: carbapenem-resistant Enterobacteriaceae

Social Network Analysis of Patient Movement Across Health Care Entities in Orange County, Florida

OBJECTIVE

Multidrug-resistant organisms (MDROs) are continually emerging and threatening health care systems. Little attention has been paid to the effect of patient transfers on MDRO dissemination among health care entities in health care systems. In this study, the Florida Department of Health in Orange County (DOH-Orange) developed a baseline social network analysis of patient movement across health care entities in Orange County, Florida, and regionally, within 6 surrounding counties in Central Florida.

MATERIALS AND METHODS

DOH-Orange constructed 2 directed network sociograms-graphic visualizations that show the direction of relationships (ie, county and regional)-by using 2016 health insurance data from the Centers for Medicare & Medicaid Services, which include metrics that could be useful for local public health interventions, such as MDRO outbreaks.

RESULTS

We found that both our county and regional networks were sparse and centralized. The county-level network showed that acute-care hospitals had the highest influence on controlling the flow of patients between health care entities that would otherwise not be connected. The regional-level network showed that post-acute-care hospitals and other facilities (behavioral hospitals and mental health/substance abuse facilities) served as the primary controls for flow of patients between health care entities. The most prominent health care entities in both networks were the same 2 acute-care hospitals.

PRACTICE IMPLICATIONS

Social network analysis can help local public health officials respond to MDRO outbreak investigations by determining which health care facilities are the main contributors of dissemination of MDROs or are at high risk of receiving patients with MDROs. This information can help epidemiologists prioritize prevention efforts and develop county- or regional-specific interventions to control and halt MDRO transmission across a health care network.

Public Health Lessons: Practicing and Teaching Public Health

The following four cases represent events that actually occurred at the local, statewide, national, and international levels. A general, succinct overview is provided of each case with references listed should the reader want to access additional resource materials. The concise format of these cases is intended to generate questions. Following the general overview of each case, I examine the lessons learned from the practitioner and educator perspective and I list the skills necessary to address the issues in the case. The reader will note that there are skills that are essential for the public health practitioner to master, whether one is in an internship, entry-level position, or the director of a public health organization and so these skills are consistently listed. I encourage the reader to regularly keep abreast of the news locally and abroad and to set aside time before a staff meeting or supervisory group meeting, or use the first few minutes of a class to discuss these issues. Ask your workforce or students, “Are we ready to handle such an event if it were to occur here?”; “What resources would we need to have accessible?”; “Have we partnered with the correct agencies in the community?”; “Do we have an established, trusted presence in the community?”; “Who else do we need on our team?”; “Do we need training in a specialty area, e.g., emergency preparedness?”; “What skills have we mastered and what skills do we need to obtain?” The discussion-based questions are endless but one runs the risk of not being prepared, either individually, or in their agency, should they not discuss how public health events are occurring around us daily. I encourage you to adapt these selected cases to use in your organization and/or classroom. Discussing these issues and reviewing the lessons learned will only help us to be better prepared public health practitioners and educators of public health students.

Epidemiology and prevention of carbapenem-resistant Enterobacteriaceae in the United States

Carbapenem-resistant Enterobacteriaceae (CRE) are multidrug-resistant organisms with few treatment options that cause infections associated with substantial morbidity and mortality. CRE outbreaks have been increasingly reported worldwide and are mainly due to the emergence and spread of strains that produce carbapenemases. In the United States, transmission of CRE is primarily driven by the spread of organisms carrying the Klebsiella pneumoniae carbapenemase enzyme, but other carbapenemase enzymes, such as the New-Delhi metallo-β-lactamase, have also emerged. Currently recommended control strategies for healthcare facilities include the detection of patients infected or colonized with CRE and implementation of measures to prevent further spread. In addition to efforts in individual facilities, effective CRE control requires coordination across all healthcare facilities in a region. This review describes the current epidemiology and surveillance of CRE in the United States and the recommended approach to prevention.