Infection Prevention & Control Engaging Stakeholders

Transcription

1 Infection Prevention & Control Engaging Stakeholders Annual Report for Nov 2011 Petra Welsh, Director Tara Donovan, Epidemiologist respect caring trust 1/60

2 INFECTION PREVENTION AND CONTROL SUSTAINING MOMENTUM Table of Contents Executive Summary... 3 Introduction... 5 Healthcare Associated Infection (HAI) Indicators... 8 Clostridium difficile Infections (CDI) Incidence... 8 Methicillin-Resistant Staphylococcus aureus (MRSA) Incidence...17 Vancomycin-Resistant Enterococci (VRE) Incidence...21 Surgical Site Infections (SSIs) Incidence...25 Best Practice Hand Hygiene Compliance...28 Reprocessing of Medical Devices...34 Outbreak Management...39 Education Memberships and Awards FH Strategic Imperatives Supported by IP&C Program Summary of Initiatives Appendices Appendix A: Infection Prevention and Control Organizational Chart (as of September, 2010)...53 Appendix B: Infection Prevention and Control Service Delivery Model...54 Appendix C: FH Acute care beds as of fiscal year end 2010/ Appendix D: Hand Hygiene...56 Table 1. Percent values of overall hand hygiene compliance in FH acute care facilities, / Table 2. Percent compliance and total # of observations for all staff by site and fiscal quarter, 2010/ Table 3. Percent compliance and total # observations by FH site and type of staff, 2010/ Table 4. Percent compliance and total # of observations by FH program and fiscal quarter, 2010/ Table 5. Percent compliance and total # of observations by FH program and type of staff, 2010/ Appendix E: Reprocessing of Medical Devices...59 Table 1. Percent compliance for acute care network facility/program audits 2010/ Table 2. Community care network facility/program audits 2010/ respect caring trust 2/60

3 Executive Summary Fraser Health Strategic Imperative: Quality and Safety Deliver exceptional service as an organization that pursues quality and is recognized nationally for its results. Strategic Objective Increase patient, client, resident, and staff safety through reduction of nosocomial infections Indicator Name Status Comments (fiscal year comparison from 2009/10 to 2010/11) CDI 0% change from 1.1 to 1.1 /1000 patient days 8 MRSA 0% change from 0.5 to 0.5 /1000 patient days 17 VRE 0% change from 0.5 to 0.5 /1000 patient days 21 Cardiac SSIs 51% increase from 2.2 to 3.7 SSIs /100 procedures 25 Hand Hygiene 10% increase from 26% to 36% compliance 28 Reprocessing 8% decrease from 84% to 76% compliance 34 Gastrointestinal & Respiratory Outbreaks N/A Increase in gastrointestinal outbreak activity, variable changes in respiratory outbreak activity Page 39 Infection Prevention and Control (IP&C) at Fraser Health (FH) is very pleased to present the 2010/2011 annual report. IP&C is a core service that is in place to assist FH in the achievement of excellence in healthcare. FH continues to prioritize patient, client, and resident safety as a key objective under the Quality and Safety portfolio that is led by Dr. Andrew Webb, Vice-President, Medicine. In a healthcare environment where accountability and transparency is at the centre of garnering public trust IP&C at FH welcomes your feedback on this report. Some of the IP&C team s recent accomplishments include: Supported Infection Prevention and Control Practitioners (IPCPs) in their roles and responsibilities that enhance local facility and program IP&C initiatives Evaluated hand hygiene initiatives across FH through a hand hygiene self-assessment mandated by the Office of the Auditor General for the province of British Columbia (BC) Developed a comprehensive hand hygiene program in response to recommendations from the Office of the Auditor General, in alignment with patient safety initiatives across FH and the province Provided leadership for the provincial hand hygiene working group and sub-working groups targeting standardized provincial hand hygiene auditing and public reporting in alignment with the clinical care management initiatives from the BC Ministry of Health Supported FH programs with hand hygiene and surveillance data, along with IP&C expertise to increase hand hygiene compliance and help drive Antibiotic Resistant Organisms (AROs) improvement initiatives Developed and implemented a comprehensive, collaborative approach to the management of AROs across FH, with special emphasis on Clostridium difficile Infection (CDI) Collaborated with Medicine program and a multidisciplinary team to purchase and install human waste macerators and disinfectors across FH; this included extensive development of RFP process and implementation plan Provided data to the Provincial Infection Control Network of BC (PICNet) in support of public provincial reporting of CDI respect caring trust 3/60

4 Collaborated with other health authorities, stakeholders, programs, organizations, and projects such as Safer Healthcare Now!, PICNet, and Public Health Continued work with the FH reprocessing manual and Quality Assurance Framework for reprocessing initiatives across FH in conjunction with the Ministry of Health reprocessing policy communiqué and the provincial reprocessing working group Key infection control strategic initiatives currently in progress include: Increasing hand hygiene compliance across FH through implementation of program-based hand hygiene auditing and a quality improvement program Leadership on the provincial hand hygiene working group Developing and implementing a comprehensive, collaborative approach to the management of AROs across FH, with special emphasis on CDI Expanding and optimizing IP&C surveillance reports to support program-based improvement initiatives across the organization Standardizing surveillance of Methicillin-resistant Staphylococcus aureus (MRSA) with the Provincial Infection Control Network of BC (PICNet) to provide provincial and public reporting Continued development of IP&C key performance indicator (KPI) reporting from the FH program quality committees to the FH Infection Control Committee to ensure program accountability and responsibility of infection prevention and control best practices Developing specific IP&C housekeeping standards for FH in collaboration with contracted service providers Participating in the Qmentum program from Accreditation Canada with on-site survey in November 2011 Consulting on major construction projects and renovations across FH related to IP&C standards and best practices Developing specific infection prevention and control construction standards in collaboration with Lower Mainland Facilities Management in alignment with national and international standards and best practices Educating and implementing the FH reprocessing standard operating procedures (SOPs) as well as further development and implementation of the reprocessing quality assurance framework Collaborating with provincial health authorities to standardize infection prevention and control initiatives Engaging and involving frontline staff in implementation of infection prevention and control best practices and improvement initiatives This report includes surveillance rates for CDI, MRSA, Vancomycin-Resistant enterococci (VRE), surgical site infections (SSIs), along with hand hygiene and reprocessing compliance rates. Improvement activities that demonstrate FH s commitment to patient, resident, and client safety, and the safety of employees, volunteers, and physicians are also highlighted. Based on this year s report, the key priorities for next year will be: Priority 1: Lead Hand Hygiene initiatives for FH to drive increase in compliance and improvement actions Priority 2: Reduction of Healthcare Associated Infections through collaborative initiatives with staff Priority 3: Successful Accreditation Canada survey of IP&C standards in Nov 2011 Priority 4: Stakeholder integration of IP&C standards on construction and renovation projects Priority 5: Implementation of Reprocessing SOPs and QA framework across the organization respect caring trust 4/60

5 Introduction The Fraser Health (FH) Infection Prevention and Control (IP&C) program s mandate is to ensure patient, resident, client, staff, physician, and visitor safety through control and prevention of infectious agents across the health authority. IP&C has a regional structure that provides consultation across FH programs as well as providing local support at each of the acute care facilities. The IP&C team provides expertise in infection prevention and control knowledge, best practices, and standards that promote patient safety efforts across FH from the front line to the site and organizational level. There is continued participation and collaboration with other health authorities, as well as local, provincial, national, and international quality and patient safety organizations and related initiatives such as Provincial Infection Control Network (PICNet), Safer Healthcare Now!, the Canadian Patient Safety Institute, the Institute for Healthcare Improvement, and Accreditation Canada. Fraser Health Authority transitioned from site-based to program management in The modification to program surveillance and reporting was implemented to facilitate accountability among the programs and foster change and improvements related to infection prevention and control initiatives. This is the first fiscal year that the IP&C program collected and reported program-level data. Quarterly program surveillance rate updates are provided to the program quality committees to share with leadership and front-line staff to inform and drive improvement initiatives. Surveillance data for a full fiscal year (2010/11) has now been captured and annual comparison will be possible next annual report. There are no benchmark comparisons for program surveillance reports nationally. Infection prevention and control across the organization is accomplished by: Surveillance, trending, and reporting of institutional and community-associated infections to increase awareness of patient safety issues and help drive improvement initiatives Engaging stakeholders in the adoption, implementation and standardization of best practices Education and collaboration with employees, physicians, patients, clients, residents, and visitors The FH IP&C program reports to the Vice-President Medicine who provides executive leadership and strategic oversight to the quality and safety of clinical care. The program is led by a Medical and an Administrative Director, Infection Prevention and Control Practitioners (IPCPs), and is supported by consultation from the Medical Microbiologists from the Department of Laboratory Medicine and Pathology, Health Promotion and Prevention, Workplace Health, and numerous other programs across the health authority. See Appendix A for Organizational chart and contact information. The IP&C Annual Report is organized in three sections: Executive Summary Healthcare Associated Infection (HAI) Indicators Surveillance Best Practice Knowledge Transfer: Education Membership and Awards FH Strategic Imperatives Supported by IP&C Program respect caring trust 5/60

6 INFECTION PREVENTION AND CONTROL SUSTAINING MOMENTUM Infection Prevention and Control Leadership Dr. Andrew Webb Vice-President, Medicine Dr. Fred Roberts Medical Director Petra Welsh Administrative Director Sandra Daniels Manager Tara Leigh Donovan Epidemiologist Maurie Maitland Strategic Transformation Lead for IP&C Administrative Assistant Karen Hofmann Infection Prevention and Control Practitioners (alphabetical order by surname) Permanent IPCPs Site Program Michael Arget RCH, QPCC (subacute beds) Cardiac Services Stephanie Cooke ARH, MMH, BH Maternal, Infant, Child, Youth Rebecca Countess RCH SSI, Cardiac Services Terry Dickson ARH, MSA Health Promotion/Prevention/Protection Kirsten Emley DH, PAH Medicine Noorsallah Esmail BH Environment Aleks Gara SMH, JPSOSC Home Health, End of Life Jacquie Hlagi Health Service Provider Residential Care Residential Care and Assisted Living Laura Holmes LMH Mental Health and Addictions Lauren Kim SMH Renal Susan Lim CGH, FCH Primary Health Care, Aboriginal Health Rhonda McLean PAH, JPSOSC Surgery Pawan Sindhar SMH Critical Care Darlene Spence BH, DH Construction Sandra Tjosvold ERH, RMH Rehab, Older Adult Janice Verbeck RCH Emergency, Trauma Casual IPCPs Amy Gill Valerie Schall Newly Hired IPCPs Shelly Garcha Amanda Giesbrecht SMH SMH RCH, SMH ARH, MMH *Please see Appendix B for alignment of IPCPs with FH sites and programs. respect caring trust 6/60

7 Acknowledgements The IP&C program would like to acknowledge the many partners and programs that have provided significant contribution to infection prevention and control initiatives across the organization, without which our achievements would not be possible. Included in this acknowledgement are the FH Executive, Medical Program Directors, Physicians, Executive Directors, and all FH programs. It is a privilege to work with dedicated, compassionate, and knowledgeable staff throughout the organization. Special thanks go to: BC Centre for Disease Control Colleagues from other provincial health authority IP&C programs Communications Community and Hospital Infection Control Association (CHICA) Canada and CHICA-BC Decision Support Environmental Services Health Promotion and Prevention Information Management Medical Microbiologists Medical Health Officers Ministry of Health Services Pharmacy Program Provincial Infection Control Network (PICNet) Quality Improvement & Patient Safety Reprocessing team partners: Sheila Konishi and Kim Beaudry Surgical Healthcare-Associated Infections Prevention Excellence (SHAIPE) Workplace Health respect caring trust 7/60

8 Incidence per 1000 Patient Days Healthcare Associated Infection (HAI) Indicators Clostridium difficile Infections (CDI) Incidence Clostridium difficile infection (CDI) is one of the most commonly acquired healthcare associated infections in industrial countries. CDI is often related to antibiotic therapy which alters the normal bacteria found in the gastrointestinal tract. CDI may present as asymptomatic colonization, massive diarrhea that may be difficult to control, toxic megacolon, and even sepsis and death. Trend * Target 20% reduction (0.9/ 1000 patient days) Actual No change (1.1/ 1000 patient days) Annual Incidence of Facility-Associated CDI in FH Acute Care Facilities April 1, 2005 to March 31, Canadian rate = 0.6 (2009) 0.0 Apr 05-Mar 06 Apr 06-Mar 07 Apr 07-Mar 08 Apr 08-Mar 09 Apr 09-Mar 10 Apr 10-Mar 11 CDI infections Facility-Assoc/1000 pt days Figure 1. Annual incidence of facility-associated CDI in FH acute care facilities per 1,000 patient days (the number of new hospital acquired cases of CDI divided by the number of inpatient days); fiscal years 2005/06 to 2010/11. * = minimal concerns: actual is meeting target and meeting Canadian benchmarks; = concern area: actual is either not meeting target or not meeting Canadian benchmarks or data points moving in negative direction or remaining level; = problem area: actual is not meeting target and not meeting Canadian benchmarks. respect caring trust 8/60

9 Incidence per 1000 patient days Incidence per 1000 patient days Annual Incidence of Facility-Associated CDI in FH by Acute Care Facility April 1, 2008 to March 31, Canadian rate = 0.6 (2009) ARH BH CGH DH ERH FCH LMH MMH MSA PAH QPCC RCH RMH SMH FH 2008/ / / Facility Figure 2. Annual incidence of facility-associated CDI in FH acute care facilities per 1,000 patient days (the number of new hospital acquired cases of CDI divided by the number of inpatient days); fiscal years 2008/09, 2009/10 and 2010/ Annual Incidence of Facility-Associated CDI by Program, April 1, 2010 to March 31, FH rate = 1.1 (Fiscal 2010/11) Medicine Surgery Critical Care Emergency Cardiac Rehab Older Adult MICY CDI Rate (Fiscal Total 10/11) # of cases Figure 3. Annual incidence of facility-associated CDI in FH acute care programs per 1,000 patient days (the number of new hospital acquired cases of CDI divided by the number of patient days), fiscal year 2010/11. respect caring trust 9/60

10 Methodology: Surveillance is completed by the IPCPs using a standardized case definition to identify cases from various sources including medical microbiology reports, admission reports, and chart reviews. IPCPs enter all cases into an internal FH acute care database. The IP&C epidemiologist extracts and analyzes the data. A diagnosis of CDI applies to a person who is an inpatient with: Acute onset of diarrhea (> 3 loose stools within a 24 hr period) without another etiology (loose stool is defined as that which takes the shape of the container that holds it). And one or more of the following: Laboratory confirmation (positive toxin or culture with evidence of toxin production) OR Diagnosis of typical pseudo-membranes on sigmoidoscopy or colonoscopy or histological/pathological diagnosis of CDI OR Diagnosis of toxic megacolon. Surveillance includes: A case as defined above occurring at least 3 consecutive days (72 hours) or more after admission OR A case as defined above with symptom onset in the community or 72 hours or less after admission to a healthcare facility, provided that symptom onset was less than 8 weeks after the last discharge from a healthcare facility. The cases are attributed to the healthcare facility from which the patient was last discharged A case as defined above that is nosocomial to the same facility (i.e. facility-associated) Reinfections are included - A case as defined above whose symptoms started greater than 2 months (60 days) from a previous C. difficile infection (as determined by the date of a previous positive laboratory test, chart note, or diagnosis by endoscopy or pathological specimen) The incidence rate is calculated as the total number of newly identified CDI cases among admitted patients that are deemed hospital acquired (i.e. facility-associated), divided by the number of inpatient days, multiplied by 1000 to generate a rate per 1000 patient days. What is the Annual Target the organization seeks to reach? The FH target rate is a 20% reduction in the incidence of CDI from the previous year. This target was not met as the FH rate of 1.1 remained constant over the past two fiscal years. Benchmark & Comparators: Each site uses their facility rates as a benchmark for CDI improvement. The overall FH acute care facility CDI rate has consistently remained above the Canadian rate provided by the Canadian Nosocomial Infection Surveillance Program (CNISP) for the past six fiscal years. The most current Canadian rate (2009) is 0.6 per 1000 patient days based on national data from 35 hospitals (adult and mixed facilities) [L.Forrester, personal communication, July 5, 2011]. Trend: What does the data show? The overall annual incidence of CDI for the past six fiscal years has fluctuated from the lowest rate of 1.0/1000 patient days in 2005/06 fiscal year to 1.4/1000 patient days (2008/09) and finally 1.1/ 1000 patient days in both fiscal years 2009/10 and 2010/11.(see Figure 1) There was variation in the 2010/11 annual CDI rates across FH acute care facilities [see Figure 2 (range; 0.1 to 1.9 per 1000 patient days) and even greater variation in quarterly CDI rates (range; 0.0 to 2.1 per 1000 patient days). The sites with higher rates affect the overall total for FH. Among the program-specific surveillance the Older Adult Program had the highest annual CDI rate of 2.8 (127 episodes) per 1000 patient days (see Figure 3) Limitations: What might have affected the quality if this measure? For hospitals with a small number of beds, e.g. MMH, an increase of 1 or 2 cases leads to a high facility rate with wide confidence intervals. This also contributes to the overall FH rate. (See Appendix C for FH acute care bed numbers for fiscal year end 2010/11) respect caring trust 10/60

11 Awareness of CDI may have led to increased case finding by increased laboratory testing, which would affect the overall FH CDI rate. FH continues to use the C. difficile cell cytotoxicity assay rather than the more sensitive nucleic acid amplification methods used in other health authorities. A more sensitive and rapid laboratory assay would improve the overall diagnosis and treatment for CDI cases. Earlier detection of CDI patients would help identify cases we are currently not treating and isolating, thus enabling prompt care and treatment and reducing the potential for transmission. Comments: The rate of CDI remained constant despite the number of facility-associated cases (numerator) increasing from 967 in 2009/10 to 1032 in 2010/11. This is due to the parallel increase in total number of patient days (denominator) increasing from 871,685 to 918,225 respectively. The increase in patient days demonstrates a higher surge capacity among acute care hospitals that could impact various known factors which contribute to the transmission of CDI including workload of staff, availability of single or isolation rooms in a facility, hand hygiene practices and compliance, previous prolonged or unnecessary antibiotic treatment, environmental cleaning practices, appropriate contact precautions, the availability of sinks in patient rooms, and the use of closed waste disinfector systems. What actions have been taken over the last year? Formed regional CDI Working Group to steer antimicrobial stewardship and reduction of CDI rates Developed CDI toolkit and created an intranet channel on FHPulse to aide with ward-level improvement work for various phases of action: getting started, change management, spreading improvements, sustaining change Developed and implemented extensive CDI reporting across FH that includes weekly reports for new cases of CDI at the unit level in all acute care facilities and quarterly program reports for the following programs: Surgery, Medicine, Emergency, Critical Care, Rehab, Cardiac, Older Adult, and Maternal Infant, Child and Youth Performed baseline hand hygiene audits for acute and residential care and provided in-the-moment feedback notices highlighting action improvement options Launched FH 1st Annual CDI Conference with keynote Dr. Jason Leitch, co-sponsored by Medicine Program and Infection Prevention & Control Created project charter for regional Antimicrobial Stewardship and piloted antimicrobial utilization study on 2 wards at BH Focused positive deviance approach with frontline champions to gain traction toward increased peer-to-peer driven changes towards best practices for infection control, environmental cleaning and hand hygiene Underwent 6-month study on enhanced bleach cleaning of environmental surfaces Continued to build momentum with Surgical Healthcare-Associated Infections Prevention Excellence (SHAIPE) Collaborative to facilitate actions and improvements for preventing healthcare-associated infections with overall aim to have cross-sectional impact on CDI, Methicillin-Resistant Staphylococcus aureus (MRSA), surgical site infections (SSIs) and catheter-associated urinary tract infections (CAUTIs) What improvement actions are planned for the next fiscal year? Build improvement collaborative for Medicine and Older Adult Program and foster the growth of CDI prevention imperatives into frontline culture and everyday practice Mobilize FH antimicrobial utilization strategies and incorporate key measures from Provincial Clinical Care Management Complete FH Housekeeping Standards for incorporation into Infection Prevention & Control Manual Implement bedpan work flow for human waste disposal from bedside to closed waste disposal system that will decrease contamination of environment and exposure risk to patients and staff respect caring trust 11/60

12 Design infrastructure to optimize workflow in future builds (SMH Critical Care Tower) that include decentralized and point-of-care bedpan waste disposal, 80% acuity areas with single rooms, and optimal ratio for hand washing stations Expand social marketing of CDI prevention strategies through electronic magazines (e-zines), patient-family focused communication and education Improve molecular diagnostic testing for quicker and earlier identification of CDI patients respect caring trust 12/60

13 Additional Epidemiological Information for CDI In 2010/11 there was a total of 1235 CDI incidence cases including new infections and reinfections; 113 (9%) were community-associated, 1122 (91%) were healthcare associated and of these, 1032/1235 (84% of the total) were facility-associated cases. COMPLICATIONS Complications are outcomes that occur within 30 days after initial laboratory test or CDI identification including history of admission to ICU, diagnosis of toxic megacolon, or gastric surgery (colectomy). A patient may experience more than one complication. Of the total new or reinfected CDI cases in FH there were 98 cases who experienced CDI-associated complications; 16 (16%) were community-associated, 82 (84%) were healthcare associated and of these 76/98 (78% of the total) were facility-associated. Table 1 shows the distribution of complications for facility-associated CDI cases by acute care facility and Table 4 shows the distribution by program. CDI-related complications by acute care facilities in FH has declined to 7% (95% CI=6-9%) in 2010/11 from 9% (95% CI=7-11%) in 2009/10. ANTIBIOTIC USE Antibiotic use has been shown to increase the risk of CDI and their usage is a major concern in acute care facilities. There were 1082 CDI incidence cases that were on antibiotics up to 6 weeks prior to the diagnosis of CDI. Sixty-one (6%) were community-associated cases, 1020 (94%) were healthcare associated, and of these 944/1082 (87% of the total) were facility-associated. Table 2 shows the distribution of antibiotic use for facilityassociated CDI cases in FH acute care facilities and Table 5 shows the distribution by program. Antibiotic use among CDI cases in FH acute care facilities has declined to 91% (95% CI= 90-93%) in 2010/11 from 93% (95% CI= 91-94%) in 2009/10. ALL CAUSE MORTALITY All cause mortality includes all causes of death within 30 days post identification/culture date, not necessarily deaths attributed to CDI. There was a total of 216/1235 (17%) deaths of any cause associated with CDI incidence cases in FH in 2010/11. Among the deaths, eighteen (8%) were community-associated cases, 198 (92%) were healthcare associated cases, and of these 183/198 (85% of the total) were facility-associated. Table 3 shows the distribution of all cause mortality of facility-associated CDI cases by acute care facility and Table 6 shows the distribution by program. All cause mortality among CDI cases in acute care facilities decreased slightly to 18% (95% CI= 16-20%) in 2010/11 from 19% (95% CI= 17-22%) in 2009/10. None of the changes from previous to this fiscal year were statistically significant. respect caring trust 13/60

14 Table 1. Complications by facility (facility-associated cases) 2010/11 Complications Facility n % ARH 7/41 17 BH 4/205 2 CGH 3/17 18 DH 0/20 0 ERH 4/45 9 FCH 0/2 0 LMH 7/116 6 MMH 0/7 0 MSA 0/1 0 PAH 3/46 7 QPCC 1/24 4 RCH 29/ RMH 1/24 4 SMH 17/269 6 Grand Total 76/1032 7% Table 2. Antibiotic use by facility (facility-associated cases) 2010/11 Antibiotic Use Facility n % ARH 38/41 93 BH 188/ CGH 16/17 94 DH 20/ ERH 44/45 98 FCH 2/2 100 LMH 111/ MMH 7/7 100 MSA 1/1 100 PAH 43/46 93 QPCC 23/24 96 RCH 183/ RMH 23/24 96 SMH 245/ Grand Total 944/ % Table 3. All cause mortality by facility (facility-associated cases) 2010/11 All Cause Mortality Facility n % ARH 12/41 29 BH 36/ CGH 3/17 18 DH 5/20 25 ERH 7/45 16 FCH 0/2 0 LMH 21/ MMH 3/7 43 MSA 0/1 0 PAH 12/46 26 QPCC 2/24 8 RCH 28/ RMH 4/24 17 SMH 50/ Grand Total 183/ % respect caring trust 14/60

15 Table 4. Complications by program (facility-associated cases) 2010/11 Complications Program n % Cardiac 6/18 33 Critical Care 31/75 41 Emergency 6/77 8 Home Health 0/12 0 Medicine 18/565 3 Maternal, Infant, 0/2 0 Child, Youth Older Adult 3/127 2 Rehabilitation 4/36 11 Surgery 8/120 7 Grand Total 76/1032 7% Table 5. Antibiotic use by program (facility-associated cases) 2010/11 Antibiotic Use Program n % Cardiac 17/18 94 Critical Care 73/75 97 Emergency 70/77 91 Home Health 10/12 83 Medicine 526/ Maternal, Infant, 2/2 100 Child, Youth Older Adult 111/ Rehabilitation 33/36 92 Surgery 102/ Grand Total 944/ % Table 6. All cause mortality by program (facility-associated cases) 2010/11 All Cause Mortality Program n % Cardiac 3/18 17 Critical Care 23/75 31 Emergency 17/77 22 Home Health 4/12 33 Medicine 97/ Maternal, Infant, 0/2 0 Child, Youth Older Adult 24/ Rehabilitation 5/36 14 Surgery 10/120 8 Grand Total 183/ % respect caring trust 15/60

16 ANALYSIS BY AGE GROUP (RELAPSES INCLUDED) When relapses were included with new cases and reinfections, there were a total of 1476 cases of CDI in 2010/11. There were 134 (9%) community-associated, 1341 (91%) healthcare associated, and of these 1219/1476 (83% of total) were facility-associated. Nine age groups were computed. Refer to Table 7 for a breakdown of number of cases, relapses, complications, antibiotics and all cause mortality among the age groups. There were no cases less than 14 years of age. Number of cases: Those aged 80 to 89 years accounted for the greatest number of cases (571; 39%) followed by 70 to 79 years (334; 23%) and 90+ years (221; 15%) among all FH acute care facilities. Relapses: Those aged 80 to 89 years had the most relapses (94; 40%) followed by 70 to 79 years (57; 24%) and 90+ years (33; 14%). Complications: The 70 to 79 year age group had the highest number of cases with complications (35; 30%) followed by 60 to 69 years (29; 25%) and 80 to 89 years (28; 24%). Antibiotic use: The 80 to 89 year age group had the greatest number of cases (504; 34%) who received antibiotics up to 6 weeks prior to the diagnosis. Those aged 70 to 79 accounted for 23% (291 cases) and 90+ year olds were 16% (201 cases). All cause mortality: There were no deaths among CDI cases ages 1 to 29 years. There were two deaths (3%) for ages 19-49, 20 (12%) deaths for ages 50-64, and 223 (19%) deaths for those aged 65+. Table 7. Outcomes by age group for all cases including new cases, reinfections and relapses, 2010/11 Age Groups Number of cases Relapses Complications Antibiotics All Cause Mortality 1 to 19 years 7 (0%) 2 (1%) 0 (0%) 7 (1%) 0 (0%) 20 to 29 years 17 (1%) 5 (2%) 2 (2%) 12 (1%) 0 (0%) 30 to 39 years 21 (1%) 2 (1%) 1 (1%) 17 (1%) 1 (0%) 40 to 49 years 41 (3%) 2 (1%) 7 (6%) 35 (3%) 2 (1%) 50 to 59 years 77 (5%) 10 (4%) 12 (10%) 63 (5%) 8 (3%) 60 to 69 years 187 (13%) 28 (12%) 29 (25%) 159 (12%) 21 (8%) 70 to 79 years 334 (23%) 57 (24%) 35 (30%) 291 (23%) 68 (27%) 80 to 89 years 571 (39%) 94 (40%) 28 (24%) 504 (39%) 109 (43%) 90+ years 221 (15%) 33 (14%) 4 (3%) 201 (16%) 45 (18%) Grand Total respect caring trust 16/60

17 Incidence per 1000 patient days Methicillin-Resistant Staphylococcus aureus (MRSA) Incidence Methicillin-resistant Staphylococcus aureus (MRSA) are strains of staphylococci that have become resistant to antimicrobial agents traditionally used to treat common skin and soft tissue infections, e.g. penicillins and cephalosporins. MRSA may be found in wound, skin, soft tissue, and bone infections as well as sites where foreign bodies have been inserted. Antimicrobial resistance makes these infections more difficult to treat and causes excessive illness, leading to increased length of hospital stay and increased morbidity and mortality. Over the past few years the incidence of MRSA in both acute care and community settings has greatly increased. Trend Target 20% reduction Actual No change (0.5 /1000 patient days) Facility-Associated Annual Incidence of MRSA in FH Acute Care Facilities April 1, 2006 to March 31, Canadian Rate = 0.6 (2009) Apr 06-Mar 07 Apr 07-Mar 08 Apr 08-Mar 09 Apr 09-Mar 10 Apr 10 - Mar 11 Total MRSA MRSA incidence Figure 4. The overall FH incidence of MRSA per 1,000 patient days; fiscal years 2006/07 to 2010/11. * = minimal concerns: actual is meeting target and meeting Canadian benchmarks; = concern area: actual is either not meeting target or not meeting Canadian benchmarks or data points moving in negative direction or remaining level; = problem area: actual is not meeting target and not meeting Canadian benchmarks. respect caring trust 17/60

18 Incidence per 1000 patient days Incidence per 1000 patient days Facility-Associated Annual Incidence of MRSA by FH Acute Care Facility April 1, 2008 to March 31, Canadian Rate = 0.6 (2009) ARH BH CGH DH ERH FCH LMH MMH MSA PAH QPCC RCH RMH SMH FH Apr 08-Mar Apr 09-Mar Apr 10 - Mar Facility Figure 5. The annual rate of MRSA in FH acute care facilities per 1,000 patient days, (the number of new hospital acquired cases of MRSA infection and colonization, divided by the number of inpatient days); fiscal years 2008/09, 2009/10 and 2010/11. Facility-Associated MRSA by Program, April 1, 2010 to March 31, FH Rate = 0.5 (Fiscal 2010/11) 0.0 Medicine Surgery Critical Care Emergency Cardiac Rehab Older Adult MICY MRSA Rate (Fiscal Total 10/11) # of cases Figure 6. Annual incidence of facility-associated MRSA in FH acute care programs per 1,000 patient days (the number of new hospital acquired cases of CDI divided by the number of patient days), fiscal year 2010/11. Methodology: Surveillance is completed by the IPCPs using a standardized case definition in order to identify cases from various sources including medical microbiology reports, admission reports, and chart reviews. IPCPs enter all cases into a FH infection control database. The IP&C epidemiologist extracts and analyzes the data. An MRSA case is defined as meeting ALL of the following criteria: respect caring trust 18/60

19 Laboratory identification of MRSA: Staphylococcus aureus cultured from a clinical or screening specimen which is oxacillin/cefoxitin resistant by standard susceptibility testing methods, or positive for penicillin binding protein 2a (PBP2a), or positive by molecular methods for the meca gene Patient must be admitted to an acute care facility A case is identified 48 hours or more after admission AND the infection or colonization was not present on admission OR MRSA is identified and the patient was admitted to the same healthcare facility within the last 12 months A case as defined above that is nosocomial to the same facility (i.e. facility-associated) The incidence rate is calculated as the total number of newly identified MRSA cases (both infections and colonizations) among admitted patients that are deemed hospital acquired (i.e. facility-associated), divided by the number of inpatient days, multiplied by 1000 to generate a rate per 1000 patient days. What is the Annual Target the organization seeks to reach? The FH target rate is a 20% reduction in the incidence of MRSA infection from the previous year. This target was not met as the FH rate of 0.5 remained constant over the past two fiscal years. Benchmark & Comparators: How does the rate compare to other areas? Each site uses their facility rates as a benchmark for MRSA improvement. The overall FH acute care facility MRSA incidence remained above the CNISP rate of 0.6 (2009) for the first three fiscal years (2006/07 to 2008/09) but decreased below the CNISP nosocomial MRSA benchmark for the past two fiscal years [L. Forrester, personal communication, February 24, 2011] Trend: What does the data show? The annual incidence of MRSA in FH acute care facilities has declined over the past three years after an increase to 0.8/1000 patient days in 2007/08 from 0.6/1000 patient days in 2006/07. The annual incidence declined in 2008/09 to 0.7/1000 patient days and then to 0.5/1000 patient days in 2009/10 and 2010/11. (See Figure 4) There was variation in the 2010/11 annual incidence of MRSA in FH acute care facilities [see Figure 5 (range 0.0 to 0.7 per 1000 patient days)} and even greater variation in quarterly MRSA rates across FH (range 0.0 to 1.2 per 1000 patient days). The sites with higher rates affect the overall total for FH. Among the program-specific surveillance the critical care program had the highest annual MRSA rate of 1.5 (78 episodes) per 1000 patient days. (see Figure 6) Limitations: What may have affected the quality of this measure? Data validation may not have been complete in earlier surveillance years, particularly with the consistency of the 12 month look-back period. Interpretation of the screening algorithm and diligence of contact tracing in identifying additional cases may vary over the years and affect the overall annual rates. Comments: Known factors which contribute to the transmission of MRSA include hand hygiene practices and compliance, the duration from MRSA identification to initiation of contact precautions, the number of available single or isolation rooms in a facility, and the environmental cleaning practices. Approximately 24% (95% CI=21-27%) of the total MRSA episodes in 2010/11 were attributed to communityassociated MRSA (CA-MRSA) compared to 22% (95% CI= 20-25%) CA-MRSA in 2009/10, a difference that is not statistically significant. The increase of community-associated MRSA is consistent with national surveillance literature 2. This is not in relation to the facility-associated annual incidence. This additional burden of CA-MRSA in acute care facilities could create a potential reservoir for ongoing nosocomial transmission. It could be 2 Simor AE, Nicolas LG, Gravel D, Mulvey MR, Bryce E, et al. Methicillin-Resistant Staphylococcus aureus colonization or infection in Canada: national surveillance and changing epidemiology, Infection Control and Hospital Epidemiology, 2010;31(4): respect caring trust 19/60

20 worthwhile to focus on community-initiatives to identify and reduce CA-MRSA in order to reduce the number of patients entering acute care facilities with MRSA. Furthermore, among the facility-associated MRSA cases, 37% (95% CI=33-41%) of cases were deemed colonized and the remaining 63% (95% CI=59-68%) of cases were deemed infections. The high incidence of MRSA infections is a concern due to the usual increased length of stay, increased provision of treatments that result in increased costs and an increase in morbidity. What actions have been taken over the last year? Surgical Program integrated improvement work to reduce MRSA with program key priority areas and hand hygiene within the SHAIPE Collaborative which was launched in Nov 2010 FH Antibiotic Stewardship Working Group implemented key strategies at RCH, BH, LMH, and ERH to improve drug utilization particularly with meropenem FH Hand Hygiene Program implemented across continuum of care that supports a cultural shift to increase hand hygiene compliance RCH enrolled in the national quality improvement initiative with Safer Healthcare Now! to reduce the incidence of antibiotic-resistant organisms using Positive Deviance and to drive cultural change with frontline practices All acute care sites with > 50 beds participated in a national antibiotic-resistant organism (ARO) Point Prevalence Study What improvement actions are planned for the next fiscal year? Mobilize FH antimicrobial utilization strategies and incorporate key measures from Provincial Clinical Care Management Complete FH Housekeeping Standards for incorporation into Infection Prevention & Control Manual Complete clinical practice guideline for Management of MRSA in residential care facilities Build accountability with the Program quality committees and incorporate the reporting of infection prevention and control KPIs through quarterly reports to the FH Quality Committees and the FH Board of Directors Plan Master Concept for new builds and design infrastructure to achieve standards such as optimal number and location of handwashing sinks and single patient rooms Increase ward-led hand hygiene audits that are performed by frontline staff to spread self-awareness and peer promotion of the 4 Moments of Hand Hygiene Participate in the provincial surveillance for MRSA following the case definitions and reporting from PICNet BC respect caring trust 20/60

21 Incidence per 1000 patient days Vancomycin-Resistant Enterococci (VRE) Incidence Vancomycin-resistant enterococci (VRE) are strains of Enterococcus sp. that have become resistant to the antibiotic vancomycin, making infections more difficult to treat. Enterococci are found as normal flora of the gastrointestinal tract in >95% of healthy individuals. The organism is able to survive on environmental surfaces for extended periods. The majority of VRE cases are asymptomatic and therefore only colonized with the organism with a small percentage off patients are infected with VRE. Trend Target No target Actual No change (0.5 /1000 patient days) Facility-Associated Annual Incidence of VRE in FH Acute Care Facilities April 1, 2006 to March 31, Canadian Rate = 0.5 (2009) Apr 06-Mar 07 Apr 07-Mar 08 Apr 08-Mar 09 Apr 09-Mar 10 Apr 10 - Mar 11 Total VRE VRE incidence Figure 7. Annual incidence of VRE in FH acute care facilities per 1,000 patient days (the number of new hospital acquired cases of VRE infection and colonization, divided by the number of inpatient days); fiscal years 2006/07 to 2010/11. * = minimal concerns: actual is meeting target and meeting Canadian benchmarks; = concern area: actual is either not meeting target or not meeting Canadian benchmarks or data points moving in negative direction or remaining level; = problem area: actual is not meeting target and not meeting Canadian benchmarks. respect caring trust 21/60

22 Incidence per 1000 patient days Incidence per 1000 patient days Facility-Associated Annual Incidence of VRE by FH Acute Care Facility April 1, 2008 to March 31, Canadian rate = 0.5 (2009) ARH BH CGH DH ERH FCH LMH MMH MSA PAH QPCC RCH RMH SMH FH Apr 08-Mar Apr 09-Mar Apr 10 - Mar Facility Figure 8. Annual incidence of VRE in FH acute care facilities per 1,000 patient days (the number of new hospital acquired cases of VRE infection and colonization, divided by the number of inpatient days); fiscal years 2008/09, 2009/10 and 2010/11. Facility-Associated VRE by Program, April 1, 2010 to March 31, FH Rate = 0.5 (Fiscal 2010/11) 0.0 Medicine Surgery Critical Care Emergency Cardiac Rehab Older Adult MICY VRE Rate (Fiscal Total 10/11) # of cases Figure 9. Annual incidence of facility-associated VRE in FH acute care programs per 1,000 patient days (the number of new hospital acquired cases of CDI divided by the number of patient days), fiscal year 2010/11. Methodology: Surveillance is completed by the IPCPs using a standardized case definition in order to identify cases from various sources including medical microbiology reports, admission reports, and chart reviews. IPCPs enter all cases into a FH infection control database. The IP&C epidemiologist extracts and analyzes the data. respect caring trust 22/60

23 A VRE case is defined as meeting ALL of the following criteria: Laboratory identification of VRE Patient must be admitted to an acute care facility A case is identified 48 hour or more after admission AND the infection or colonization was not present on admission OR VRE is identified and patient was admitted to the same healthcare facility within the last 3 months. A case as defined above that is nosocomial to the same facility (i.e. facility-associated) The incidence rate is calculated as the total number of newly identified VRE cases (both infections and colonizations) among admitted patients that are deemed hospital acquired (i.e. facility-associated), divided by the number of inpatient days, multiplied by 1000 to generate a rate per 1000 patient days. What is the Annual Target the organization seeks to reach? No annual target was established for VRE in fiscal year 2009/10. Benchmark & Comparators: How does the rate compare to other areas? Each site uses their facility rates as a benchmark for VRE improvement. The overall FH acute care facility rate of VRE has remained equal to the CNISP nosocomial VRE rate of 0.5 (2009) for the past two fiscal years. [L. Forrester, personal communication, February 24, 2011] Trend: What does the data show? The annual FH acute care facility VRE incidence had steadily increased over the first 3 years of surveillance and has now decreased to 0.5/1000 patient days (see Figure 7). There was variation in the 2010/11 annual FH acute care facility VRE rates [see Figure 8 (range 0.0 to 0.8 per 1000 patient days) and even greater variation in quarterly VRE rates across FH acute care facilities (range 0.0 to 0.9 per 1000 patient days). The sites with higher rates affect the overall total for FH. Among the programspecific surveillance the critical care program had the highest annual VRE rate of 1.6 (83 episodes) per 1000 patient days (see Figure 9). Limitations: What may have affected the quality of this measure? Data validation may not have been complete in earlier surveillance years, particularly with the consistency of the 12 month look-back period. Interpretation of the screening algorithm and diligence of contact tracing in identifying additional cases may vary over the years and affect the overall annual rates. Comments: There are a combination of factors which contribute to the transmission of VRE including hand hygiene practices and compliance, the duration from VRE identification to initiation of contact precautions, the number of available single or isolation rooms in a facility, and the environmental cleaning practices. This additional burden of VRE in acute care facilities could create a potential reservoir for ongoing nosocomial transmission. Four percent (95% CI=3-6%) of VRE episodes in 2010/11 were deemed community associated cases compared to 2% (95% CI=2-4%) in 2009/10, a difference that is not statistically significant. This percentage is significantly lower than the 24% (95% CI=21-27%) of CA-MRSA cases identified in 2010/11. Thus communityassociated VRE does not impact FH acute care facilities as much as MRSA and resources and initiatives to identify and reduce CA-MRSA entering FH acute care facilities would be beneficial. Furthermore, among the facility-associated MRSA cases, 75.5% (95% CI=71-79%) were deemed colonized and the remaining 24.5% (95% CI= 21-29%) were deemed infections. In response to the lower rate of infections, it may be beneficial to reduce resources and efforts to conduct facility and program-wide surveillance of VRE respect caring trust 23/60

24 and consider a more targeted approach focusing on high risk units (e.g. ICU, hematology, oncology and transplantation wards) to prevent transmission. 3 What actions have been taken over the last year? Surgical Program integrated improvement work to reduce the incidence of antibiotic-resistant organisms with program key priority areas and hand hygiene within the Surgical Healthcare-Associated Infections Prevention Excellence (SHAIPE) Collaborative which was launched in Nov 2010 FH Antibiotic Stewardship Working Group implemented key strategies at RCH, BH, LMH, ERH to improve drug utilization particularly with meropenem FH Hand Hygiene Program implemented across continuum of care that supports a cultural shift to increase hand hygiene compliance RCH enrolled in the national quality improvement initiative with Safer Healthcare Now! to reduce the incidence of antibiotic-resistant organisms using Positive Deviance and to drive cultural change with frontline practices. All acute care sites with beds>50 participated in a national antibiotic-resistant organism (ARO) Point Prevalence Study What improvement actions are planned for the next fiscal year? Mobilize FH antimicrobial utilization strategies and incorporate key measures from Provincial Clinical Care Management. Complete FH Housekeeping Standards for incorporation into Infection Prevention & Control Manual Build accountability with the Program quality committees and incorporate the reporting of infection prevention and control KPIs through quarterly reports to the FH Quality Committees and the FH Board of Directors Plan Master Concept for new builds and design infrastructure to achieve standards such as optimal number and location of handwashing sinks and single patient rooms Increase ward-led hand hygiene audits that are performed by frontline staff to spread self-awareness and peer promotion of the 4 Moments of Hand Hygiene 3 Zirakzadeh A, Patel R. Vancomycin-resistant enterococci: colonization, infection, detection and treatment. Mayo Clinic Proceedings. 2006:81(4): respect caring trust 24/60

25 Incidence per 100 surgical procedures Surgical Site Infections (SSIs) Incidence Surgical site infection (SSI) initiatives are being implemented across various sites and programs as part of the overall FH surgical quality improvement program. FH Quality Improvement and Patient Safety and the IPCPs are involved in process improvement and developing the outcome measures for these initiatives. Examples of the improvement initiatives include preoperative screening and appropriate antibiotic prophylaxis prior to surgery. Surgical procedures include total hip and knee arthroplasty, general and vascular surgery. Cardiac SSIs Trend Target 3.8 SSIs per 100 procedures (NHSN benchmark) Actual 51% increase (3.7/ 100 procedures) CABG/CABG Valve Procedures Annual SSI rates, April 1, 2003 to March 31, Total rate DSWI* rate 4.0 NHSN SSI rate = 3.8 (2008) NHSN DSWI rate = 1.0 (2008) / / / / / / / /11 Total rate DSWI* rate Fiscal Year Figure 10. Annual SSI rates, both total and deep sternal wound infections for Coronary Artery Bypass Grafting (CABG) or CABG with valve replacement procedures, 2003/04 to 2010/11. *Deep Sternal Wound Infection. Table 8. Type and site of SSI for post CABG and CABG with Valve replacement for April 1, 2010 to March 31, Superficial Deep Site n (%) n (%) Graft (leg) 15 (65%) 0 Sternum 1 (4%) 7 (30%) Total 16 7 * = minimal concerns: actual is meeting target and meeting Canadian benchmarks; = concern area: actual is either not meeting target or not meeting Canadian benchmarks or data points moving in negative direction or remaining level; = problem area: actual is not meeting target and not meeting Canadian benchmarks. respect caring trust 25/60

26 Organism Cultured Causative Organism of Cardiac surgery SSIs, April to March 31, 2011 Acinetobacter spp Candida albicans Enterobacter colacae Enterobacter spp Klebsiella pneumoniae Mixed enterics MRSA Pseudomonas aerogenosa Serratia marcescens Staphylococcus aureus (MSSA) staphylococcus coagulase negative Streptococcus pyogenes B Streptococcus pyogenes G Yeast No growth Graft/Donor Site Superficial Sternal Wound Deep Sternal Wound Number of organisms Figure 11. Causative organism of cardiac surgery SSIs, April to March 31, Note: multiple organisms for a single specimen are included Methodology: This past fiscal year 2010/11 a modification was made to the cardiac surveillance data collection methods. A SSI-specific query was developed by Information Technology that navigates through the microbiology lab specimens entered in the FH-wide Meditech system. It is now possible to retrieve all positive culture results from cardiac surgery patients that have been collected and entered in any FH acute care facility. This is an expansion of data collection from the previous method of only obtaining positive specimens at Royal Columbian Hospital (RCH) where surgeries were performed. An IPCP conducts chart reviews and collects data according to a FH SSI tool and enters the data into an FH infection control database. The FH case definition is based on the U.S. Center for Disease Control and Prevention s National Healthcare Safety Network (NHSN) case definition for SSI. Every identified cardiac SSI is collected and reported. The FH IP&C epidemiologist analyzes and ensures data quality. The denominator value is provided by the surgical program. The annual rate of cardiac SSIs is calculated as the number of nosocomial cardiac SSIs divided by the number of total cardiac surgeries performed multiplied by 100 procedures. RCH is the only FH site that performs cardiac surgeries and therefore is the only site conducting surveillance. When a graft site infection did not specify the extent of tissue involvement the SSI was labeled as a superficial wound infection. What is the Annual Target the organization seeks to reach? FH intends to remain below the NHSN benchmarks of 3.8 SSIs per 100 procedures of coronary bypass w/chest and donor incision, risk index 2,3 and 1.0 DSWIs per 100 coronary artery bypass graft procedures, risk index 2,3. Benchmark & Comparators: How does the rate compare to other areas? The overall cardiac SSI rate remains below the established benchmark and the DSWI rate is slightly above. Trend: What does the data show? The 2010/11 overall cardiac SSI rate of 3.7 (95% CI=2.3 to 5.6) remains slightly below the NHSN benchmark of 3.8 SSIs per 100 procedures but increased from 2.2 (95% CI= ) per 100 procedures in 2009/10; though not significantly. The FH Cardiac DSWI rate in 2010/11 was 1.1 (95% CI= ) which is slightly above the NHSN benchmark of 1.0, but is a decrease from 1.6 (95% CI= ) in 2009/10. respect caring trust 26/60

27 Limitations: What may have affected the quality of this measure? Post discharge surveillance is not performed which would result in an underreporting of superficial SSIs. Infections that do not require re-admission to the hospital would not be captured. False negative culture results (i.e. due to antibiotic use) could result in missed cases. Comments: As a result of improvements to data collection from only RCH to all FH lab data there is an increase in the scope of cardiac SSI surveillance with the ability to capture more superficial infections. This likely impacted the rate of SSIs due to an increased number of graft site SSIs being captured compared to prior years. What actions have been taken over the last year? The cardiac program has joined the SHAIPE Collaborative The Surgical Healthcare-Associated Infection Prevention Excellence Collaborative. The focus and goal for the cardiac team is to reduce the incidence of graft site infections. An automated query has enabled us to capture more cases through enhanced surveillance techniques During the upcoming fiscal year there are plans for the Cardiac Program to take a more active role with post-discharge surveillance and for the IP&C Program to partner with the Surgical Program for the surveillance of other SSIs What improvement actions are planned for the next fiscal year? FH IP&C will continue to partner with the surgical program and Quality Improvement and Patient Safety to monitor rates and identify areas for improvement including revisions to the SSI reporting form and report generation respect caring trust 27/60

28 % Compliance Best Practice Hand Hygiene Compliance Hand hygiene is a critical patient safety initiative and one of the most effective, well-known measures to reduce the transmission of HAIs worldwide. Hand hygiene education and training is being provided across FH through new employee orientation sessions along with on-the-job training and in-services provided by IPCPs. Monitoring hand hygiene compliance using continuous observational audits and on-going improvement activities are continuing, to align with the Canadian Patient Safety Institute s Safer Healthcare Now! initiative and with Accreditation Canada s Required Organizational Practices. Trend Target 100% increase (54% compliance in FH) Actual 36% compliance overall (10% increase) 100% 90% 80% 70% Hand Hygiene Compliance in FH Acute Care Facilities / /11 Overall compliance 30% % % % 2009/10 38% 2010/11 60% 50% 40% 30% 20% 10% 0% ARH BH CGH DH ERH FCH LMH MMH MSA PAH RCH RMH SMH QPCC (acute) FHA Facility Figure 12. Comparison of hand hygiene compliance audits in FH acute care facilities conducted in 2005, 2007, 2009, 2009/10 and 2010/11. (See Appendix D, Table 1 for rate values) = minimal concerns: actual is meeting target and meeting Canadian benchmarks; = concern area: actual is either not meeting target or not meeting Canadian benchmarks or data points moving in negative direction or remaining level; = problem area: actual is not meeting target and not meeting Canadian benchmarks. respect caring trust 28/60

29 Compliance (%) Compliance (%) Hand Hygiene Compliance Among All Staff, by Site and Fiscal Quarter, 2010/11 100% 80% 60% 40% 20% 0% Qtr 1 Qtr 2 ARH BUH CGH DH ERH FCH LMH MMH PAH RCH RMH SMH QPCC Qtr % 17.3% 50.6% 29.7% 28.1% 35.3% Qtr % 44.3% 69.1% 27.2% 48.2% 41.3% 49.5% 62.5% 33.9% 25.7% 30.4% 31.1% 12.0% 42.3% 26.2% Res- Cont Res- Owned Figure 13. Hand hygiene compliance among all staff, by site and fiscal quarter 2010/11. (See Appendix D, Table 2 for rate values) 100% Hand Hygiene Compliance by Site and Type of Staff, 2010/11 80% 60% 40% 20% 0% ARH BUH CGH DH ERH FCH LMH MMH PAH RCH RMH SMH QPCC Nurse 49.2% 47.9% 74.0% 31.0% 56.9% 43.6% 55.4% 71.6% 36.3% 29.4% 38.2% 37.3% 20.7% 62.5% 28.0% Physician 34.2% 34.6% 40.2% 16.7% 55.3% 0.0% 38.2% 64.6% 43.8% 19.0% 24.3% 22.8% 0.0% 33.3% 30.5% Clinical 34.5% 54.1% 60.0% 7.7% 87.5% 40.0% 14.9% 55.6% 34.1% 14.4% 33.3% 15.9% 25.0% Other 21.9% 14.9% 50.0% 19.0% 0.0% 9.6% 39.3% 11.8% 0.0% 0.0% 4.0% 0.0% 33.3% 18.9% Res- Cont Res- Owned Figure 14. Hand hygiene compliance by FH acute care site and type of staff, 2010/11. (See Appendix D, Table 3 for rate values) respect caring trust 29/60

30 Compliance (%) Compliance (%) Hand Hygiene Compliance Among All Staff, by Program and Fiscal Quarter, 2010/11 100% 80% 60% 40% 20% 0% Qtr 1 Qtr 2 Crit Care Emerg End of Life Home Older MICY Med MH&A Health Adult Qtr % 48.0% 0.0% 35.3% 29.4% Qtr % 50.7% 20.4% 46.9% 35.8% 32.0% 61.5% 32.9% 64.0% 28.7% 30.3% 26.2% 46.0% 63.0% 40.9% PHC Public Res Rehab Renal Health Figure 15. Hand hygiene compliance among all staff by FH program and fiscal quarter, 2010/11. (See Appendix D, Table 4 for rate values). Care Surg Lab Pharm 100% Hand Hygiene Compliance by Program and Type of Staff, 2010/11 80% 60% 40% 20% 0% Crit Care End of Home Emerg Life Health MICY Med MH&A Older Adult Nurse 30.0% 55.5% 25.1% 45.0% 44.7% 35.6% 63.8% 39.6% 64.0% 38.8% 34.9% 28.0% 49.8% 61.9% Physician 28.0% 44.6% 10.9% 50.0% 77.8% 27.1% 75.0% 7.7% 7.5% 21.7% 30.9% 27.5% 63.0% 40.6% Clinical 23.5% 56.8% 19.7% 40.0% 17.7% 11.9% 62.5% 0.0% 18.2% 25.0% 25.0% 31.3% 25.0% Other 0.0% 6.7% 3.0% 58.3% 7.3% 9.3% 33.3% 8.3% 9.1% 5.3% 18.8% 14.0% 21.4% PHC Public Res Rehab Renal Health Figure 16. Hand hygiene compliance by FH program and type of staff, 2010/11. (See Appendix D, Table 5 for rate values). Methodology: Hand hygiene audits are an ongoing performance measure across Fraser Health Authority (FHA). Audits were completed throughout November 2010 to March 2011 (fiscal quarters 3 and 4) by FHA personnel, health care workers on units, and IPCPs. A total of 8955 observations of hand hygiene practice (7681 acute care and 1274 residential care) were collated in the database as of June 30, 2011 and are included in this report. Some electronic data entry of audit results for fiscal 2010/11 were delayed and recently collated for this report. Care Surg Lab Cardiac Trauma Imaging Cardiac Trauma Imaging Pharm respect caring trust 30/60

31 Observations were completed in all acute care sites and select residential contracted and owned and operated sites 4. Multiple FHA programs were audited. All auditors received training based on the new hand hygiene audit toolkit available to all staff via the Intranet. Auditors collected the hand hygiene observations on hard copy audit forms and entered the data into an electronic hand hygiene InfoPath form. All hand hygiene data was collated and stored in a permission-protected FH SharePoint site. Microsoft Access and Excel were used for analysis and presentation of data. Observations for hand hygiene compliance included before and after opportunities based on the four moments for hand hygiene. Both use of soap and water and alcohol hand sanitizer were included for compliance. Missed opportunities occurred when hand hygiene compliance was not adhered to. Each audit included a minimum of five health care workers who were observed a minimum of five and up to ten opportunities for hand hygiene; a valid audit required at least twenty-five total observations up to a maximum of fifty. This requirement was to ensure the reliability of the results and provide consistency when comparing percentage of hand hygiene compliance over time. Classification of staff/health care worker types is collated into four category codes: Nurse Physician Clinical Other RN/RPN, LPN, Care Aide/Student Aide, Student (Nursing) Physician, Medical Student/Resident Medical Technician, Respiratory Therapy, Lab personnel, Porter, Social Worker, Rehab Therapy, Dietician Housekeeping, Maintenance, Volunteer, Food Services In 2005 and 2009/10 project individuals (registered nurses trained by IP&C) performed the observations. In 2007 and 2009 the IPCPs conducted the audits. What is the Annual Target the organization seeks to reach? The annual target for hand hygiene compliance in FH is 100%. Benchmark & Comparators: How does the rate compare to other areas? Hand Hygiene compliance rates are not yet publicly posted within BC, however, Ontario compliance in acute and long term care sites is 77% (Ontario Patient Safety Indicator Report, fiscal year 2010/11, available at: Trend: What does the data show? Overall hand hygiene compliance was 36% in 2010/11 including acute (38% compliance) and residential care (27% compliance) facilities; an increase of 10% from 2009/10 (26% compliance) across FH. Limitations: What may have affected the quality of this measure? Data collection methods and personnel have varied over the years and should be considered when comparing rates. The variety of auditors could impact inter-observer variability (i.e. variation between program auditors, IPCPs and dedicated hand hygiene auditors) or intra-observer variability (i.e. variation in an observer s classification over time) but use of the best practice hand hygiene toolkit should minimize this variability by standardizing the education provided to auditors and the methodology used when conducting hand hygiene audits. Some sites, programs and types of staff have a smaller total number of observations and may not be as representative of the overall population. 4 All acute care sites, Residential Contracted site (Laurel Place), Residential Owned and Operated sites (Baillie House, Bradley Centre, BH Transitional Care Unit, CareLife Fleetwood, Cottage Worthington Pavillion, DH Extended Care Unit (ECU), Eagle Ridge Manor, Fellburn Care Centre, Fraser Hope Lodge, Heritage Village, LMH ECU, MMH ECU, PAH ECU, Queen s Park Care Centre). respect caring trust 31/60

32 The 2010/11 hand hygiene observations included both acute and residential care facilities. The majority of observations in the 2005 and 2009/10 audits were in acute facilities, whereas the 2009 audits included Residential Owned and Operated facilities. The total number of observations (n=8955) was much higher than in previous years, making comparison of results difficult. The total number of observations included in the 2007 (n=596) and 2009 (n=1212) audits were much lower than the 2005 baseline (n=2246) and 2009/10 audits (n=2832). The 2010/11 audits include a more representative sample of the FH population. Comments: The first figure demonstrates hand hygiene compliance results from five different auditing periods; 2005 to 2010/11. The 2005 and 2009/10 audits included a larger number of observations, n=2246 and n=2832 respectively, with n=596 observations in 2007 and n=1212 in For facility-specific rates refer to Appendix D, Table 2. What actions have been taken over the last year? Approval of hand hygiene action plan by Office of the Auditor General, FHA Executive, Clinical Integration Executive Committee and Board Quality Performance Committee (QPC) Developed a best practice hand hygiene toolkit (available on FH Pulse) Developed a hand hygiene page on FH Pulse with interactive tools and resources Developed and posted hand hygiene clinical care practice guidelines Updated hand hygiene communication materials, e.g. posters, pamphlets and decals Completed and posted the online hand hygiene education module for all FH staff and physicians in the online education module, A-Tutor Hired Strategic Transformation Team consultant to lead hand hygiene initiatives for a one year term Developed hand hygiene database for direct electronic data entry by front line staff conducting the audits Developed hand hygiene reporting system to generate program and site compliance reports Hand hygiene presentations at more than 25 leadership meetings at the site and regional levels Engaged physician champions Completed Leading for Transformation project: Physician Engagement for hand hygiene Chaired Provincial hand hygiene working group Drafted construction guidelines for placement of hand hygiene stations Submitted IM case for change to develop an integrated Infection Control surveillance database, incorporating hand hygiene audits along with other surveillance indicators What improvement actions are planned for the next fiscal year? Distribute and post new hand hygiene posters and other social marketing materials across all programs and sties at FH Launch e-learning using A-Tutor to track online hand hygiene education module completion Review hand hygiene alcohol based hand rub products for new contract starting July 2011 Work directly with Physician leadership to develop role modeling and other physician led hand hygiene improvement strategies respect caring trust 32/60

33 Develop Provincial hand hygiene practice guidelines, policy and multi-level reporting, including a public provincial hand hygiene report Take hand hygiene action plan to site and program leadership meetings, as well as program QPCs, to engage in the development of program-led improvement initiatives Design a training/education program based on assessment of staff/leadership needs Conduct an infrastructure assessment of access to hand hygiene stations/products Identify strategies to ensure hand hygiene guidelines in appropriate clinical decision support tools Develop IT infrastructure to support compliance monitoring and reporting at the unit level respect caring trust 33/60

34 % Compliance Reprocessing of Medical Devices Reprocessing involves the complete cycle of cleaning, transportation, disinfection, sterilization, and storage, and use of medical devices and patient care equipment according to best practices and standards. In June 2007 the British Columbia Ministry of Health mandated a comprehensive practice review of reprocessing activities for critical and semi-critical medical devices and patient care equipment by health authorities to increase patient safety by ensuring that all health authorities are in full compliance with established standards for reprocessing of medical devices and patient care equipment [Health Canada and the Canadian Standards Association]. FH completed the audits and implemented a series of regional reprocessing polices and remediation activities including Standard Operating Procedures (SOPs) to guide the reprocessing of patient care equipment and medical devices.. The organization will continue to monitor reprocessing practices through a committee structure which will report to the FH QPC. Trend Target 95% Compliance Actual 76% Compliance (8% decrease) FH Reprocessing Compliance, /11 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% FH Overall FH Acute Care FH Community Care* 2007 Audit 51% 60% 25% 2008 Audit 82% 82% 76% 2009/10 Audit 84% 85% 81% 2010/11 Audit 76% 79% 70% * includes residential care facilities except in 2010/11 Audit. No residential facilities were audited during this fiscal year. Figure 17. FH reprocessing compliance comparison, /11. = minimal concerns: actual is meeting target and meeting Canadian benchmarks; = concern area: actual is either not meeting target or not meeting Canadian benchmarks or data points moving in negative direction or remaining level; = problem area: actual is not meeting target and not meeting Canadian benchmarks. respect caring trust 34/60

35 % Compliance % Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% FH Acute Care Facility Reprocessing Compliance, /11 FH Overall ARH BH CGH DH ERH FCH LMH MMH PAH RMH RCH SMH 2007 Audit 62% 57% 62% 76% 69% 61% 73% 54% 54% 50% 2008 Audit 82% 78% 81% 91% 87% 81% 83% 76% 78% 85% 2009/10 Audit 83% 77% 84% 82% 88% 83% 2010/11 Audit 81% 81% 80% 70% 84% 80% 88% 90% 83% 77% 80% 73% Facility Figure 18. FH acute care facilities reprocessing compliance, /11. (See Appendix E, Table 1 for acute care facilities percent compliance) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% FH Overall SPD Program Reprocessing Compliance, /10 ARH BH CGH DH ERH FCH LMH MMH PAH RMH RCH SMH 2007 Audit 78% 83% 68% 92% 84% 70% 81% 75% 76% 70% 2008 Audit 97% 96% 94% 97% 98% 98% 98% 99% 95% 99% 2009/10 Audit 96% 99% 97% 94% 98% 96% 96% 97% 96% 95% 97% 92% 2010/11 Audit 99% 99% 99% Facility Figure 19. Sterile Processing Department (SPD) program reprocessing compliance comparison, /11. respect caring trust 35/60

36 % Compliance % Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% FH Acute Service Programs Reprocessing Compliance, /11 FH Overall Critical Care ER Mat/ Child Med In- Pt 2007 Audit 60% 15% 37% 26% 64% 61% 33% 41% 77% 2008 Audit 82% 74% 68% 66% 71% 78% 85% 73% 68% 97% 71% 2009/10 Audit 81% 75% 79% 77% 81% 84% 90% 78% 79% 96% 80% 72% 2010/11 Audit 77% 81% 71% 61% 81% 78% 67% 80% 99% 69% 84% Facility Amb Care OR Rehab Resp SPD Surgical In-pt Medical Imaging Figure 20. FH acute service programs reprocessing compliance comparison, /11. (See Appendix E, Table 1 for acute care programs percent compliance) FH Community Care Network Programs Reprocessing Compliance, 2010/ Renal Health Promotion and Prevention Home Health MICY-Audiology MICY-Speech Primary Health Care Community Portfolio Figure 21. FH community care network programs reprocessing compliance, 2010/11 (See Appendix E, Table 2 for community care network percent compliance) What is being measured? A provincial audit tool is being used to measure compliance to reprocessing best practice and standards that includes CSA standards and Ministry of Health BC Best Practice Guidelines for the Cleaning, Disinfection and Sterilization of Medical Devices in Health Authorities for all critical and semi-critical medical devices and patient care equipment. All FH areas, programs, and facilities that reprocess critical and semi-critical medical devices are being audited according to a pre-determined schedule. respect caring trust 36/60

37 Methodology: A computerized program is used to conduct the audit assessments, consisting of an electronic audit tool and computer database. This setup enables standardized audit score entry with functionality to record both auditor and department/service managers comments at the time of the audit. All audit responses (Yes, No or N/A) and comments are then automatically imported into a database that allows generation of compliance results for portfolio, facility, and program groupings. This electronic tool allows a standard approach and increased efficiency of the audit team. The SPD auditor extracts the data from an internal FH reprocessing database and provides to the IP&C epidemiologist who reports the data. The audits are being conducted by subject matter experts of the FH reprocessing team; one team member is an IPCP and the other is a member from the SPD. The audits are conducted either individually or as a team of two, based on the complexity and perceived risk of the reprocessing activities of that program. The audits are conducted in conjunction with the program managers and front line staff responsible for the reprocessing activities for that program. FH sites and programs are audited on a three-year reprocessing audit sampling plan. Programs that perform reprocessing such as SPD, Operating Rooms, Ambulatory Care, Medical Imaging, and Respiratory, as well as other areas performing high risk procedures (such as programs or facilities that operate a table top sterilizer or high level disinfectant) will be audited annually. Areas that have been assessed as low risk based on steps they complete within the reprocessing cycle such as Emergency Rooms, Medical and Surgical In-Patient areas, and Critical Care, Residential facilities, Home Health, Health Promotion and Prevention, and Mental Health facilities will be audited on a three-year cycle. Please see Appendix E for sites and programs audited for 2010/2011. What is the Annual Target the organization seeks to reach? The goal of the organization is to reach 95 % compliance in the third year of auditing. Benchmark & Comparators: How does the rate compare to other areas? All health authorities within BC are required to conduct reprocessing audits using the provincial audit tool. The scope and approach for the audits varies by health authority and no rates are publicly available. FH has been recognized by the Ministry of Health as auditing units and programs more broadly than other Health Authorities making it impossible to compare results. Trend: What does the data show? When compared to the prior fiscal year the reprocessing compliance varies across all sectors at FH. Some sites improved and others worsened compared to 2010/11. The biggest improvement for FH programs was in SPD (99% from 96%) and Medical Imaging (84% from 72%). Operating rooms (78% from 90%) and surgical inpatient (69% from 80%) departments had the largest decline in compliance. Limitations: What may have affected the quality of this measure? The audits are a subjective interpretation based on the audit question and interpretation of the standards by the auditor, as well as the knowledge of the audit participants. As each audit year progressed, the auditors were asked to evaluate more thoroughly. Year one answers were based on respondents answers, year two evaluated through a show me request, year three preemptively identified high risk equipment and requested information about the reprocessing of this. As year four is being initiated, additional equipment reprocessing is being evaluated and work is being completed to standardize to best practice. Comments: No audits were conducted for Residential facilities for fiscal 2010/11 (April 1, 2010 to March 31, 2011) as FH was converting from an annual to a fiscal reporting structure. There are a number of initiatives underway that are considered regional in scope that are being remediated by the FH reprocessing task group, not by the individual programs or facilities. These areas score a non-compliance score on the audit tool which affects their overall compliance rate. FH auditors applied standardized answers to some of the questions as a FH regional responsibility. Examples include development of a FH-wide policy for purchasing and dissemination of the education requirements; without the development and dissemination of the policy, units and programs cannot be held accountable for respect caring trust 37/60

38 meeting a question that has not been supported yet by FH. Therefore, the majority of audits include six questions/answers that have a prequalification of No that are not unit specific. If those questions are extrapolated, the unit results fall within a 95% compliance result. What actions have been taken over the last year? Implemented a practice shift to ensure reprocessing practice standards are met (e.g. change to disposables where reprocessing is impractical, or redesign work flow and equipment inventory levels to shift work to Sterile Processing Departments) Aligned practice with manufacturer s instructions and ensure they are current and appropriate Updated work instruction and process documentation Provided staff training and education modules for reprocessing and infection prevention and control best practices to identify core competency levels for staff and front line managers. Identified where facility redesign/upgrade is needed to address infection control issues Identified where facility infrastructure redesign/upgrade is needed to address reprocessing infection prevention and control requirements such as adding sinks in Medical Imaging Purchased equipment/instruments as required to comply with reprocessing policies and practice standards. Units such as ORs continue to identify gaps and purchase additional equipment to reduce the use of Flash Sterilizers Continued development of a quality assurance plan to support a sustainable practice shift throughout FH and to ensure annual compliance with the objectives of the reprocessing audits Created a series of standard operating procedures for all steps in the reprocessing cycle applicable across the continuum of care in FH Developed an education program to support the core competency requirements for reprocessing as defined by the provincial working group Provided support and consultation to programs and facilities in developing and implementing remediation plans by program/service/site for audit remediation activities Worked with the BC Ministry of Health to provide an update to the Best Practice Guidelines document. What improvement actions are planned for the next fiscal year? Implementation and education of the Reprocessing SOPs Education and training of reprocessing standard operating procedures through a train-the-trainer methodology Implementation of the Quality Assurance framework Continued development of the Reprocessing for Patient Safety webpage that provides reprocessing resources to all FH staff Completion of the FH purchasing policy that will ensure representation of the end user, sterile processing department, purchasing, and infection prevention and control prior to the purchase of all medical devices requiring reprocessing Continued work and improvement initiatives for critical and semi-critical medical devices, quality control and documentation of efficacy testing of disinfectant solutions, improvement of storage areas for medical devices and patient care equipment, and assisting units/programs with expanding reprocessing to encompass non-critical medical devices On-going work with the Provincial Reprocessing Working Group to standardize processes and practices across the province and review of critical incidents that affects reprocessing practices respect caring trust 38/60

39 Total Number Affected INFECTION PREVENTION AND CONTROL SUSTAINING MOMENTUM Outbreak Management Gastrointestinal Outbreaks Table 9. Gastrointestinal outbreaks in FH facilities, April 1, 2010 to March 31, 2011 Type of Facility # of Outbreaks # of patients/ residents affected # of staff affected Length of Outbreak (days) Ward Closure Duration of Ward Closure (days) Acute HSP Owned & Operated Total Note: The length of outbreak days is the duration of the date outbreak declared and the date outbreak declared over no ward closure details collected for HSP facilities Gastrointestinal Outbreaks in FH Acute and Residential Care Facilities, April 1, 2010 to March 31, Q1 Q2 Q3 Q4 # of Patients # of Staff Duration (days) Fiscal Quarters Figure 22. Numbers of both patients and staff affected during gastrointestinal outbreaks in FH acute, Health Service Provider (HSP) and Owned & Operated facilities from April 1, 2010 to March 31, Table 10. Etiological agents identified from gastrointestinal outbreaks in FH declared between April 1, 2010 and March 31, Type of Facility Norovirus Adenovirus Unknown/ None Acute HSP Owned & Operated Total respect caring trust 39/60

40 Total Number Affected Gastrointestinal Outbreaks in FH Acute and Residential Care Facilities by Fiscal Year / /11 # of Patients # of Staff Duration (days) Fiscal Year Figure 23. Gastrointestinal outbreaks in FH acute and residential care facilities, fiscal years 2009/10 and 2010/11. What is being measured? The total number of gastrointestinal outbreaks and their impact on acute and residential [Health Service Provider (HSP) and Owned & Operated] facilities in FH including the number of patients and staff affected, the duration of outbreaks and ward closure details. Methodology: Surveillance and management of all outbreaks is completed by IPCPs who are notified by frontline staff of symptoms consistent with gastroenteritis which include otherwise unexplained vomiting and/or diarrhea. IPCPs use a standardized case definition to determine if a gastrointestinal outbreak should be declared (i.e. 3 or more cases of gastroenteritis in patients or staff in a 4 day period). There are Standardized Infection Control gastrointestinal outbreak management protocols for acute and residential care facilities. Acute and Owned & Operated outbreaks are reported through a gastrointestinal outbreak investigation notification (GION) system which includes a FH-wide posting of all outbreaks that have commenced and declared over. Surveillance and reporting of HSP facilities is completed by Public Health. IPCPs monitor and record all acute care and Owned & Operated outbreaks in a FH internal database. Public Health monitors and records all residential HSP facilities. Trend: What does the data show? There were 72 reported outbreaks of gastrointestinal illness in FH; 33 outbreaks occurred out of a total of 14 acute care facilities, 25 outbreaks occurred out of a total of 66 HSP facilities, and 14 outbreaks occurred out of a total of 15 Owned & Operated facilities between April 1, 2010 and March 31, 2011 (see Table 9). Fifty-four outbreaks were confirmed Norovirus, 1 outbreak was confirmed adenovirus and the remaining 16 outbreaks were unconfirmed gastroenteritis (refer to Table 10). The total duration of gastrointestinal outbreaks was 797 days (see Figure 22). The duration of outbreaks ranged from 0-24 days for acute care, 0-28 days for HSP and 7-25 days for Owned and Operated facilities. The comparison of fiscal years (Figure 23) shows an increase in the total number of patients (685 to 1032) and staff (224 to 310) affected from 2009/10 to 2010/11 respectively, and an increase in the number of days associated with gastrointestinal outbreaks (590 to 797). This affect could be due to the many confirmed norovirus outbreaks which indicate high activity throughout the region. Further norovirus is readily transmitted respect caring trust 40/60

41 and can spread throughout facilities quickly affecting many patients and staff, especially considering the increase in surge capacity and overcrowding in acute care facilities. Limitations: Some details were not available for all reported outbreaks and have been excluded from the results. Details regarding management of outbreaks in different types of facilities is not well known and could impact the duration of an outbreak and number of people that are affected. Information pertaining to ward closures is not routinely collected and reported. The information provided refers to a portion of the outbreaks and is not complete for all outbreaks reported. In future it will be valuable to ensure details about management of outbreaks and ward closures is obtained. What actions have been taken over the last year? Implemented Contact Precautions Plus for early identification and additional precautions for patients with diarrhea symptoms (emphasis is on washing hands with soap and water) Developed GI Outbreak Nursing Worksheet to simplify early identification and tracking of new clients with new onset of GI symptoms Implemented Acute Care Algorithm for Immediate Management of Possible Gastroenteritis Implemented Weekend GI Outbreak declaration at BH utilizing Site Leaders and Pathologists-On-Call What improvement actions are planned for the next fiscal year? Developed protocol for Medical Microbiologists-On Call to declare GI Outbreaks during the weekend to rest of FH acute care sites respect caring trust 41/60

42 Total Number Affected Respiratory Outbreaks Table 11. Respiratory outbreaks in FH declared between April 1, 2010 and March 31, Type of Facility # of Outbreaks # of patients/ residents affected # of staff affected Length of Outbreak (days) Ward Closure Duration of Ward Closure (days) Acute HSP Owned & Operated Total Note: Scenario A/B outbreaks only, the length of outbreak days is the duration of the date outbreak declared and the date outbreak declared over no ward closure details collected for HSP facilities Respiratory Outbreaks in FH Acute and Residential Care Facilities, April 1, 2010 to March 31, Q1 Q2 Q3 Q4 # of Patients # of Staff Duration (days) Fiscal Quarters Figure 24. Numbers of both patients and staff affected during respiratory outbreaks in FH HSP and Owned & Operated facilities by Quarter from April 1, 2010 to March 31, 2011 (Note: quarter based on outbreak declared start date). Table 12. Etiological agents identified from respiratory outbreaks in FH declared between April 1, 2010 and March 31, Type of Facility Influenza A Entero/ Rhinovirus Human Metapneumovirus RSV Unknown/ None Not Tested Acute HSP Owned & Operated Total respect caring trust 42/60

43 Total Number Affected Respiratory Outbreaks in FH Acute and Residential Care Facilities by Fiscal Year / /11 # of Patients # of Staff Duration (days) Fiscal Year Figure 25. Respiratory outbreaks in FH acute and residential care facilities, fiscal years 2009/10 and 2010/11. What is being measured? The total number of respiratory outbreaks and their impact on acute and residential [HSP and Owned & Operated] facilities in FH including the number of patients and staff affected, the duration of outbreaks and ward closure details. Methodology: Surveillance and management of all acute care and Owned & Operated outbreaks is completed by IPCPs and entered in a FH internal database. IPCPs are notified of symptoms consistent with respiratory illness by front line staff and use a standardized respiratory outbreak case definition to determine if a respiratory outbreak should be declared (i.e. 2 or more staff/residents with new or worsening cough in a unit or area within a 7-day period). There are Standardized Infection Control respiratory outbreak management protocols for acute and residential care facilities. Respiratory illness that is considered mild and common cold-like in most of those affected is considered a Scenario C outbreak for identification purposes but is not deemed severe enough to be reportable and is therefore not typically included in surveillance. Acute and Owned & Operated outbreaks are reported through a respiratory outbreak investigation notification (RION) system which includes a FH-wide posting of all outbreaks that have commenced and declared over. Surveillance and reporting of HSP facilities is completed by Public Health. Trend: What does the data show? There were 14 reported outbreaks of respiratory illness in FH; none in acute care, 12 outbreaks in HSP contracted facilities (out of a total of 66), and 2 outbreaks in Owned & Operated facilities (out of a total of 15) between April 1, 2010 and March 31, 2011 (see Table 11). This is a decrease compared to the 24 total reported respiratory outbreaks last fiscal 2009/10; likely attributed to the lack of H1N1 activity this past influenza season. Among the 14 outbreaks, the most common etiologic agents identified were 4 outbreaks confirmed as Influenza A and 4 Enterovirus/Rhinovirus (See Table 12 for the remaining list). The total duration of respiratory outbreaks was 147 days; 140 days for the 12 HSP outbreaks, and 7 days for the 2 outbreaks in Owned & Operated facilities (see Table 11). The comparison of fiscal years (Figure 25) shows a slight increase in the total number of patients affected from 166 in 2009/10 to /11 but a decrease in the number of staff affected (121 to 66). There was a large respect caring trust 43/60

44 decrease in the number of days associated with respiratory outbreaks from 415 in 2009/10 to 147 in 2010/11. This reduction is likely due to the reduction of ph1n1 influenza activity in FH facilities. Limitations: Some details were not available for all reported outbreaks and have been excluded from the results. Respiratory and influenza-like illness activity is likely under-reported due to the interpretation of the case definition and the difficulty of identifying symptoms that meet the criteria of new or worsening cough. Information pertaining to ward closures is not routinely collected and reported. The information provided refers to a portion of the outbreaks and is not complete for all outbreaks reported. In future it will be valuable to ensure ward closure details are collected. Comments: There were two Scenario C respiratory outbreaks in an Owned & Operated facility that experienced a full and partial ward closure respectively. For one outbreak an entire ward was closed to admissions and transfers due to an increase in illness transmission among residents and the other outbreak triggered one wing to be closed (a partial ward closure). What actions have been taken over the last year? Developing Acute Care Respiratory Algorithm in conjunction with Emergency Program for early identification and management of patients presenting with suspect respiratory or febrile illness Provided Flu Schools pre-influenza season to contracted and owned & operated residential care facilities in conjunction with Public Health, Infection Control, Workplace Health Annual Respiratory Illness Planning (can get more info from Terry) What improvement actions are planned for the next fiscal year? Complete and implement the respiratory algorithm respect caring trust 44/60

45 Serretia Marcescens Outbreak During this past fiscal year there was an outbreak and follow-up investigation of Serratia marcescens (S. marcescens) cluster in Royal Columbian Hospital, a tertiary care centre in Fraser Health. The study coordinators included Michael Arget and Rebecca Countess (IPCPs at RCH), and a medical microbiologist Dr. Dale Purych. Serratia marcescens is a well known cause of hospital-acquired infections. Since many people are colonized with S. marcescens, it can easily spread throughout a hospital when infection control measures are inadequate. The purpose of this study is to describe a cluster of nosocomial S. marcescens infections between June 1 and September 30, 2010 at Royal Columbian Hospital (RCH). Methodology: A review of laboratory data was conducted to determine cases of S. marcescens during the time period in question. Retrospective chart reviews were conducted to determine case specific variables such as age, sex, surgery, location of infection/colonization. Both environmental and clinical samples were collected and typed using the Vitek 2.0 system. A subset of clinical samples (6) was sent for Pulsed Field Gel Electrophoresis (PFGE) to investigate genetic relationship. What does the data show? Forty-one clinical samples of S. marcescens were resulted with 25 cases identified as nosocomial to RCH. Sixteen cases underwent cardiac surgery; 6 underwent other surgery, and 2 remaining cases were related to time spent in the Intensive Care Unit (ICU). S. marcescens was isolated from a variety of sites: blood (3), sputum (7), leg incisions (5), urine (5), other wounds (5). One environmental culture yielded colonies of Gram negative bacilli in a sink, but no samples grew S. marcescens. Both typing and PFGE showed a variety of S. marcescens strains with two cases sharing identical PFGE patterns. Comments: These findings suggest that infection control measures in the cardiac surgical program need to be reviewed to identify potential sources of contamination. What actions have been taken over the last year? Infection prevention and control practices were reviewed and several recommendations were implemented: including removing aerators in patient sinks, fixing leaking faucets, de-cluttering of patient care areas, creating a system to discard opened liquid bottles, and educating staff on hand hygiene and appropriate use of personal protective equipment IP&C was added as a standing item in the cardiac program team and quality meetings The CSICU and cardiac step-down units participated in two quality improvement programs: the Canadian Patient Safety Institute s New Approach to Controlling Superbugs program and the FHA Surgery Program s SHAIPE collaborative, positively changing practice at the bedside related to infection control and patient safety Increased hand hygiene compliance in CSICU from 35% in Dec to 90% in early June 2011 What improvement actions are planned for the next fiscal year? Improvement work will continue in both of these units to ensure infection prevention and control standards and best practices are integrated in everyday cardiac clinical practices Preventing dehiscence of surgical leg wounds and evaluating the cardiac surgical infection surveillance program respect caring trust 45/60

46 Education Types of Education Provided by IPCPs: Types of Education Number of Hours Spent Workshops + Presentations 164 New Employee Orientation 119 Hand Hygiene 487 Reprocessing of Medical Devices 188 Construction 271 Influenza + Immunizations 80 Tuberculosis 135 Clostridium Difficile 225 Outbreaks: GI, Respiratory 117 Routine Practices 485 Transmission-based precautions 121 Antibiotic Resistant Organisms 194 Safety Huddles, In-services, Family Support 282 Consultations with Public Health and Third 107 Party Providers Internships and mentorships for students 185 Mentorship of new IPCPs 199 The IP&C team provides all relevant infection prevention and control education to FH staff, patients, visitors and residents across the continuum of care including acute and residential care, support services, Home Health, Health Promotion and Prevention and third party providers to name a few. Educational resources such as the Hand Hygiene, MRSA and VRE pamphlets for patients and families are updated as needed to ensure recommendations are based on current evidence-based industry standards and guidelines. This year, IPCPs also began the task of reviewing and rewriting portions of the Infection Control Manual and are committed to reviewing and updating essential sections every three to five years. Education of FH staff members has expanded to on-line modules for orientation and Hand Hygiene readily accessible through the FH intranet. Additionally, education modules have also been provided on the FH internet to ensure all staff areas have access. Two 4 th year Bachelor of Science nursing students from Vancouver Community College completed a course project focused on Hand Hygiene with Fraser Health from October 2010 to February Michael Arget (IPCP) and Tara Donovan (Epidemiologist) acted as preceptors to the students and helped them successfully complete their course requirements. Additional modules/manuals/guidelines are currently under development for the standardization of roles, responsibilities and expected outcomes for both Environmental Controls and Construction. The target date for completion of final versions is spring of respect caring trust 46/60

47 Memberships and Awards The leadership team is proud to announce that Mike Arget was nominated for the FH Above and Beyond award by the ICU program for his improvement initiatives through safety huddles. Another award presented was to Sue Lim for developing and using a song developed for a wandering minstrel to promote hand hygiene. All IPCPs participate on regional committees such as PICNet, Professional Practice, Environmental, Residential Care, Blood and Body Fluid, Joint Workplace Health/Public Health/IP&C as well as QPCs for the program(s) they cover. All IPCPs are members of CHICA-BC and CHICA-Canada. Three FH IP&C employees are CHICA-BC executive committee members; Pawan Sindhar (President), Stephanie Cooke (Secretary) and Tara Donovan (Treasurer). The IP&C epidemiologist is co-chair of the CHICA-Canada surveillance and applied epidemiology interest group. The IP&C epidemiologist is co-chair of the Epidemiologists Community of Practice BC (EpiCoPBC), a PICNet Surveillance Steering Committee member, and a member of both the Provincial hand hygiene evaluation and reporting sub-working groups. respect caring trust 47/60

48 FH Strategic Imperatives Supported by IP&C Program 1. Great Workspaces a. Improving wellbeing b. Supporting feedback c. Retention and recruitment d. Professional development 2. Quality and Safety a. Development of Reprocessing Standard Operating Procedures (SOPs) b. Hand hygiene c. Clostridium difficile infections (CDI) initiatives d. Catheter Associated Urinary Tract Infection (CAUTI) work 3. Research and Development a. Evidenced based practice development b. Use and reprocessing of the elastomeric half-face respirator during high usage times such as pandemics c. Translate knowledge into action 4. Capacity a. Supporting construction projects b. Development of Information Technology infrastructure 5. Progressive Partnerships a. SHAIPE collaborative b. National Surveillance Quality Improvement Program (NSQIP) c. BC Ministry of Health d. QMentum/Accreditation Canada e. PICNet f. Provincial Infection Prevention and Control committee Summary of Initiatives 1. Improving wellbeing, supporting feedback, retention and recruitment, and professional development To ensure that staff members feel that they are in a great working environment, FH participates in an international engagement survey called Gallop Q12, which is an anonymous survey to gauge staff satisfaction and find out how they feel about the organization and their leadership team. The leadership team is committed to improving job satisfaction and has developed and initiated a plan to promote leadership development, provide staff education opportunities and connect the staff through team building exercises. The leadership team has also developed additional positions to start to reduce the workload on IPCPs. Over the last year, an additional 2.0 FTEs, a 1.0 FTE temporary manager position, and an additional casual position have been added. The leadership team has also committed to providing financial support to advance the professional development of our employees. The leadership team has committed to allowing IPCPs up to nine days of paid leave for education that supports the IP&C program which is congruent with the union contracts. The leadership team has also approved various conferences and in-services, and has supported the IPCPs to lead and promote education of interest to them. This has lead to multiple in-services on topics such as positive deviance, Public Health reporting and a physician lead tuberculosis lecture. Staff members have also been encouraged to rotate the chairing of the monthly IP&C meetings to develop facilitation skills. Some members have been supported to expand their knowledge base through recognized infection prevention and control courses, as well as develop leadership skills through FH based education such as Leading for Engagement and Clear Leadership. respect caring trust 48/60

49 2. Reprocessing of medical devices, hand hygiene, CDI, CAUTIs Based on a provincial directive from the BC Ministry of Health, FH initiated Reprocessing SOPs which were completed in April These SOPs were based on the BC Best Practice Guidelines for Reprocessing of Critical and Semicritical Medical Devices, 2007, CSA guidelines as well as industry standards such as through the Association for Professionals in Infection Control. We developed education modules, knowledge quizzes and competency requirements for every step in the reprocessing cycle. As one of FH s recognized priorities, this year will ensure dedicated IPCPs disseminate the manual and, using a train-the-trainer approach, inform other educators how to use the modules to ensure knowledge, understanding and compliance with reprocessing steps. A FH-wide Hand Hygiene campaign, including Give germs the rub and It s okay to ask... was launched at all acute care health facilities in A FH audit tool was created and a health authority-wide baseline audit was completed. Ceiling danglers, stickers and posters have been distributed and are being installed throughout the health authority. Post audits, compliance reports are distributed to the manager. While the program was instigated by IPCPs, it is recognized that hand hygiene should be owned by all. We are working on engaging staff auditors to support programs and develop their own plan for improvement initiatives. To support the programs, we have created a hand hygiene toolkit that provides education and auditing tools, video links as well as our hand hygiene guidelines. Additionally, the hand hygiene campaign supports posting of the hand hygiene site average audit results on units and in other public areas. Another FH initiative developed in 2011 is the goal to reduce CDI by 50% by Working with leaders in both the surgery program and the medicine program, different methodologies have been adopted to deal with these infections. Action teams are being developed to bring tools and resources together to individualize change initiatives such as environmental controls and antibiotic stewardship. This initiative also incorporates the hand hygiene audits and toolkit. The FH CDI initiative also includes IPCP generated reports that indicate weekly nosocomial infections of CDI at each acute care facility broken down by unit. These reports are ed to staff at each respective facility for review and posting on units and in other public areas. In 2010, Noorsallah Esmail (IPCP at BH) worked with Environmental Services and high endemic CDI units to develop a trial of twice daily environmental disinfection with a sporicidal agent to determine if the increased frequency of cleaning with a sporicidal would lead to a decrease in CDI rates. Due to unforeseen circumstances, the results of the trial were inconclusive. CAUTI work has begun in some hospitals within FH. The recommendations from the IPCPs include assistance with determining the indications for catheter use as well as supporting the Programs that are high risk for CAUTI with education and guidance through semi-annual audits and reports. 3. Evidenced based practice development, reprocessing of the elastomeric half-face respirator, translate knowledge into action IPCPs conduct research based on the most updated, published research. The goal is to make available this information and support the integration of this evidence into practice. This is done through reconstruction and dissemination of the updated sections within the IP&C manual as well as provision of in-services, presentations, and consultations. Terry Dickson has begun a WorkSafeBC project directed by FH Occupational Health and Safety to determine the reprocessing needs and guidelines for the elastomeric half-piece respirator during widescale use. A grant was provided for this project that falls under the category of INNOVATION AT WORK. IPCps have also been committed to translating knowledge into practice. Examples of development of processes that support IPCP initiatives include: development of a CDI nursing checklist, gastrointestinal illness management algorithm, Contact Precautions Plus signage, CDI spot check, CDI best practices audit tool, environmental cleaning fluorescent marker audit tools. The IPCPs work diligently with units and programs to support the growing needs of ensuring compliance with and standardization of infection prevention and control practices. respect caring trust 49/60

50 4. Supporting construction projects This past year has been extremely busy for the IP&C team with new construction and renovations. Onsite IPCP s have had to deal with an increasing number of projects as the facilities in FHA mature. IPCPs request involvement throughout the design, construction or renovation and commissioning of projects to ensure infection control standards that protect the patient from infection are met. Darlene Spence has been the lead and project contact for most of the construction projects throughout FH. The following is a list of a few major construction projects worked on in 2010/2011: JPSOPC (Jimmy Pattison Surgical Outpatient Clinic) Surrey Tower Design Panorama Ridge/New Westminster Hemodialysis Units Riverview Relocation Projects Additionally, IPCPs provided support and guidance for other projects and deficiencies such as: o Floods most of the FHA facilities are aging and over time, problems with pipes leaking or rupturing causing facility damage increase. Research leading to additionally education requirements for floods was required. o Redesign and renovation of rooms previously altered for conversion back to patients rooms to increase capacity. These rooms required assessment, reinstallation and update of medical gases, sinks and bathrooms. o Increase need for supply storage space, resulting in additional renovations that must meet HVAC standards and guidelines. 5. SHAIPE collaborative, NSQIP, BC Ministry of Health, PICNet, Accreditation Canada SSIs can result in an increase in morbidity and mortality, longer hospital stays and substantial increases in the cost of healthcare. In collaboration with the surgical SHAIPE collaborative, IP&C has become involved via NSQIP initiatives, in the development of provincial standards for reporting and program specific improvement initiatives. IP&C supports the work of the NSQIP Quality team and is developing 2.0 FTEs to support the work that is being done. IP&C staff members have been working with the Office of the Auditor General, BC Ministry of Health and PICNet over the past year on a number of initiatives with provincial standardization the expected outcome. These initiatives include Hand Hygiene, Reprocessing of Medical Devices, CCM, standardized communications such as parameters for multiuse vials in nuclear medicine and endoscope reprocessing in physician and surgeons offices and outpatient clinics. The IPC leadership team is also committed to providing safe, quality patient care. Working through the Qumentum process with Accreditation Canada provides knowledge and insight into how to improve patient safety by implementing the Required Organizational Practices and ensuring the organization is meeting the Infection Prevention and Control Standards. respect caring trust 50/60

51 Terminology and Abbreviations Adenovirus a virus that is responsible for upper respiratory infections in children and adults. ( Annual Target - A goal that is set on a yearly basis ARH Abbotsford Regional Health ARO Antibiotic Resistant Organism Benchmark - A point of reference for judging value, quality, change, or the like; standard to which others can be compared BH Burnaby Hospital Causative Organism The organism causing the infection CA-MRSA Community-Associated Methicillin-resistant Staphylococcus aureus (MRSA) CAUTI - Catheter-Associated Urinary Tract Infection CGH Chilliwack General Hospital Clostridium difficile Infection (CDI) CDI is a micro-organism that produces a toxin that can cause diarrhea and serious illness of the gastrointestinal tract. Generally, C. difficile rarely cause problems in healthy people, however, CDI can be serious in people with co-morbid illnesses, elderly, or have weakened immune systems. In rare instances it can be fatal. CNISP - Canadian Nosocomial Infection Surveillance Program. A collaboration including the Canadian Hospital Epidemiology Committee (CHEC), a subcommittee of the Association of Medical Microbiology and Infectious Disease (AMMI) and the Centre for Infectious Disease Prevention and Control (CIDPC) of the Public Health Agency of Canada (PHAC). ( CSA Canadian Standards Association DH Delta Hospital Enterovirus a virus often found in respiratory secretions (e.g., saliva, sputum, or nasal mucus) and the stool of someone with an infection; affects millions of people each year worldwide. ( ERH Eagle Ridge Hospital Facility-associated - a case that is acquired and identified at the same facility (i.e. nosocomial to the same facility) Facility Type - A healthcare facility categorized by the range of services offered FCH Fraser Canyon Hospital FH Fraser Health Hand Hygiene - Preventing the spread of illness through washing hands with soap and water or cleaning hands with alcohol based hand-rubs. Healthcare Associated Infections (HAI) also Nosocomial Infections - Infections patients get while staying in any healthcare facility, which include micro-organisms from other patients, the environment, or staff. Not to be confused with facility-associated infections which are acquired and identified at the same facility (nosocomial to the same facility) HSP Health Service Provider Human Metapneumovirus (hmpv) a virus common in the winter season, especially among children ( IP&C Infection Prevention and Control respect caring trust 51/60

52 IPCP Infection Prevention and Control Practitioner Influenza-Like Illness (ILI) acute onset of respiratory illness symptoms which are similar to influenza but are usually caused by other viruses or bacteria. ( Indicator - A statistical measurement that shows how well something is working or operating KPI Key Performance Indicator LMH - Langley Memorial Hospital Methicillin-resistant Staphylococcus aureus (MRSA) - Staphylococcus aureus is micro-organism that is normally found on the skin and in the nose of healthy people. Some strains have become resistant to the common antibiotics used to treat infections. MRSA is a type of Staphylococcus aureus that is resistant to antibiotics commonly used to treat skin and soft tissue infections, including penicillins and cephalosporins. Staphylococcus aureus can cause minor skin infections such as boils or infections in a surgical incision site. Methodology - The methods, principles, and rules used to for the activity or result MMH Mission Memorial Hospital MSA Worthington Pavillion Subacute Care Norovirus is a ribonucleic acid (RNA) virus that is the leading cause of epidemic non-bacterial outbreaks of gastroenteritis around the world. Norovirus affects people of all ages. It is transmitted through food and water contaminated with feces or by person-to-person contact and by aerosolization of the virus on contaminated surfaces. ( PAH Peace Arch Hospital PICNet - Provincial Infection Control Network a collaborative group of healthcare professionals who aim to prevent and control healthcare associated infections. The group works under the aegis and accountability framework of the Provincial Health Services Authority (PHSA). ( QPC Quality Performance Committee QPCC Queen s Park Care Centre Rhinovirus frequently referred to as the common cold ; the most common viral infective agents among humans. The virus is transmitted by aerosolization of respiratory droplets that contaminate surfaces or person-to-person contact. ( RMH Ridge Meadows Hospital RCH Royal Columbia Hospital RSV Respiratory syncytial virus causes infection of the lungs and breathing passages and is a major cause of respiratory illness in children. RSV is easily spread by droplets containing the virus when someone coughs or sneezes. ( SHAIPE- Surgical Healthcare-Associated Infections Prevention Excellence Source - The person or thing that gave the information SMH Surrey Memorial Hospital Trend - The general movement or direction of change Vancomycin-Resistant Enterococci (VRE) - Enterococci are micro-organisms that are commonly found in the stomach and bowels of healthy people. Some bacteria have become resistant to antibiotics used to treat infections. Vancomycin is an antibiotic used to treat serious infections. VRE is a type of Enterococci that has become resistant to Vancomycin. These organisms rarely cause illness in healthy people. However, when VRE gets into open cuts and skin sores, they can cause infections. Occasionally, VRE can also cause more serious infections of the blood or other body tissues. respect caring trust 52/60

53 Appendices Appendix A: Infection Prevention and Control Organizational Chart (as of September, 2010) respect caring trust 53/60