APIC CHAPTER 13 Journal Club January 17, 2018 Presented by: Talia Lefkowitz, BSN, RN, CIC Mount Sinai Hospital

Contact tracing with real-time location system: A case study of increasing relative effectiveness in an emergency department Contact tracing with real-time location system: A case study of increasing relative effectiveness in an emergency department American Journal of Infection Control, Volume 45, Issue 12, 1308-11 Thomas R. Hellmich MD, Casey M, Clements MD, PhD, Nibras El-Sherif MBBS, Kalyan S. Pasupathy PhD, David M. Nestler MD, MS, Andy Boggust MD, Vickie K. Ernste DNP, RN, Gomathi Marisamy BS, Kyle R. Koenig BS, M. Susan Hallbeck PhD, CPE, PE Affiliated with Mayo Clinic, Rochester, MN

Background Contact tracing is a critical strategy required for timely prevention and control of infectious disease outbreaks Conventional methods (chart review, staff interviews) are imperfect: Time-consuming (30-60 minutes) Can miss a significant number of potential exposures Failure to identify persons in contact with infected patients: Increases the risk of transmission Places healthcare workers and patients at risk Disrupts healthcare services Costly for healthcare systems

Background New technology Real-time location systems (RTLS) May identify exposed individuals in a timely, efficient, and exhaustive manner Becoming increasingly affordable Real-time location systems (RTLS) Radiofrequency identification (RFID) tracking RFID in healthcare settings Face-to-face contact frequency and duration Identify the most and least connected health care workers with patients This study compares current method (chart review) and RTLS tracking for confirmed pertussis cases in an emergency room

Materials and Methods Equipment 54,450 sq ft ED and radiology (supporting ED services) 194 in-ceiling, passive RFID readers 734 antennas 212 locations System was reliable for 6 months before data collection Core ED staff wore RFID-enabled ID tags Some ancillary staff in ED did not have RFID-enabled ID tags

Materials and Methods Study protocol Retrospective case study 9 cases of confirmed pertussis June 14- August 31, 2016 Large ED of tertiary medical center 74,000 patient encounters per year All cases diagnosed within 1-2 days after ED visit, none admitted to hospital

Materials and Methods Study protocol (continued) Existing contact tracing protocol Review of EMR (Infection control and nurse leadership) Possible exposure included any health care worker with face-to-face contact with index patient in exam room or triage area and documented in EMR RTLS event mapping Identified patients and staff, colocations and movement over time and space Then, list of possible exposures limited to colocation in ED exam rooms or triage areas where droplet exposures are most likely < 5 minutes All possible exposures were offered standard prophylaxis

Materials and methods Analysis Compared number and roles of possible exposures identified via EMR vs RTLS Used descriptive statistics and paired t tests Correlation between length of stay (LOS) and number of contacts identified by each methodology

Results 9 cases of pertussis total EMR RTLS Identified 45 potential contacts 13 were identified by EMR alone (the other 33 were also identified by the RTLS) RTLS Identified 77 contacts Of the 77, 45 were identified by RTLS alone (the other 32 were also identified by the EMR) RTLS identified 2X possible contacts than EMR (P<.01) Increased the average contacts per case from 5/case to 10/case

Discussion Statistically significant positive correlation with ED LOS and RTLS-identified contacts Increase LOS of contagious patients increases potential for nosocomial spread The longer the stay = the more encounters with healthcare workers RTLS saves time and resources RTLS may reduce recall bias RTLS failed to identify 13 healthcare workers: 4 were not given RFID, 6 RNs were missed (their antenna has since been moved), 1 MD badge not read, 1 MD not wearing correct RFID badge, and 1 RN not picked up unclear RTLS is costly, need to justify

Discussion Study limitations which make it less generalizable Small sample size Only one ED Only one disease Did not include the mitigating effect of PPE use Did not take cost into account

Conclusions RTLS identified more potential contacts than traditional method Technology can accelerate the process of active screening and facilitate timely cessation in the chain of transmission RTLS may be even more beneficial in tertiary care medical systems with higher acuity; event mapping using RTLS is customizable to pick up brief exposures in the event of high-risk emerging infections transmitted by airborne spread