Breakdowns in Communication Lead to Outbreaks

10/18/17 By Dana Szymkowiak

communicationCommunication failures between healthcare facilities can lead to infection outbreaks. A two-year research study conducted by OSU/OHSU College of Pharmacy, the Oregon Health Authority, and other collaborators suggests that statement is true. Researchers focused on an opportunistic pathogen associated primarily with infections among patients who have compromised immune systems and are in health care facilities known as Acinetobacter baumannii. The pathogen is extensively drug-resistant and can contain many antibiotic resistance genes that can be transmitted to other organisms. Multiple sites in the Pacific Northwest were studied, where “scientists identified 21 cases, including 16 isolates, of Acinetobacter baumannii that contained a rare gene responsible for resistance to the carbapenem class of antibiotics.”

Among the studied facilities, patients’ transfer history and isolates’ genetic profiles showed how the pathogen spread from facility to facility. Surprisingly, a lack of inter-facility communication aided the spread of the pathogen. “The findings support a recent Oregon law requiring written notification from the discharging facility to the receiving facility anytime a patient carrying a multidrug-resistant organism, or other infection requiring transmission precautions, is transferred.”
Jon Furuno, co-author of the study and associate professor in the College of Pharmacy explains, “it just makes sense that you would want to alert a receiving facility if patients have a specific drug-resistant organism. The discharging facility needs to include that information with the discharge summary or somewhere on the chart, and the receiving facility needs to know where to look for it.” Furthermore, lead author and pediatric infectious disease specialist, Genevieve Buser comments, “An entire chain of transmission can be prevented if staff at a receiving facility know about a patient’s multidrug-resistant organism status. This outbreak might not have been identified if not for a new, limited, voluntary surveillance system in Oregon and an astute infection preventionist.”

Reporting of an Acinetobacter baumannii infection is not required by most public health jurisdictions in the United States, and clinical laboratories generally do not test for an organism’s underlying genetic resistance mechanisms. Though, proper communication can ensure appropriate contact precautions are taken.

The CDC and the National Institutes of Health supported the study. Findings were recently published in Infection Control & Hospital Epidemiology.