Annual Report

Transcription

1 Annual Report Infection Prevention and Control May, 2014

2 Table of Contents Executive Summary... 1 IPC Manual... 2 HAI Surveillance... 2 Hand Hygiene... 3 Reprocessing... 4 Outbreak Management... 4 Tuberculosis (TB)... 4 Education... 5 Key Priorities 2014/ Introduction... 6 Infection Prevention and Control Program... 8 IPC Leadership... 8 IPC Practitioners... 8 IPC Consultants... 8 Acknowledgements... 9 Healthcare Associated Infection (HAI) Indicators Clostridium difficile Infection (CDI) Methicillin-Resistant Staphylococcus aureus(mrsa) Carbapenemase-Producing Enterobacteriaceae (CPE) Vancoymcin Resistant Enterococci (VRE) Best Practice Hand Hygiene Compliance Reprocessing of Medical Devices Outbreak Management Appendix A: Structure and Accountability for IPC Program Appendix B: FH Acute Care Beds Appendix C: CDI Case Management & Risk Assessment Forms Appendix D: Hand Hygiene Compliance Appendix E: Reprocessing Compliance High Risk Appendix F: Reprocessing Compliance Low Risk Appendix G: Terminology and Abbreviations Table of Figures Figure 1: Number of new CDI and facility associated CDI incidence rate per 10,000 patient days by fiscal year for FH Figure 2: Number of new CDI and healthcare associated CDI incidence rate by FH program, 2013/ Annual Report: Page ii

3 Figure 3: Number of new CDI and healthcare associated CDI incidence rate by FH program, 2013/ Figure 4: Number of new MRSA and facility associated MRSA incidence rate per 10,000 patient days by fiscal year for FH Figure 5: Number of new MRSA and facility associated MRSA incidence rate by FH site, 2013/ Figure 6: Number of new MRSA and facility associated MRSA incidence rate by FH program, 2013/ Figure 7: Number of VRE (infections and colonizations) by month and year for FH Figure 8: Comparison of hand hygiene compliance by fiscal year in FH acute care sites Figure 9: Hand hygiene compliance among all staff by FH site, 2013/ Figure 10: Hand hygiene compliance among all staff by FH program, 2013/ Figure 11: Hand hygiene compliance by health care provider group for FH overall, 2013/ Figure 12: Reprocessing compliance by sector and fiscal year for FH overall Figure 13: Reprocessing compliance in high risk areas, SPD & OR, 2012/2013 & 2013/ Figure 14: Reprocessing compliance for low risk areas, FH community sector, 2013/ Figure 15: Comparison of Gastrointestinal Illness outbreaks in acute care sites by type of outbreak and fiscal year Figure 16: Gastrointestinal illness outbreaks in acute care facilities by type of outbreak and month, 2012/2013 & 2013/ Figure 17: Gastrointestinal illness outbreaks in acute care facilities by FH city, 2012/2013 & 2013/ List of Tables Table 1: CPE in FH, 2013/ Table 2: VRE specimen source, 2013/ Table 3: Linezolid use FH, 2013/ Table 4: Hand hygiene compliance by type of FH facility, fiscal year 2013/ Table 5: Etiological agents identified from declared Gastrointestinal Illness outbreaks in FH acute care by fiscal year Annual Report: Page iii

4 Table 7: Percent compliance for high risk areas in FH acute care and JPOCSC, fiscal years 2012/13 & 2013/ Table 8: Percent Compliance for Low Risk Areas, FH Community Sector Annual Report: Page iv

5 Executive Summary Strengthen infection prevention and control FH High Priority Initiative: Improve Patient Safety Indicator Name Status Improvement Target 2013/2014 Actual Page # CDI Reduction in Rate <6.0* 4.1* 11 MRSA Reduction in Rate < 7.0* 5.0* 19 CPE N/A N/A Baseline data 63 cases 25 Hand Hygiene Compliance Hand Hygiene Observations Increase in compliance 80% 79% 34 Increase in observations 120, , Reprocessing Compliance Outbreak Management Increase in compliance(high-risk areas) Increase in compliance (low-risk areas) Reduction in # of CDI Outbreaks 95% 96% 40 85% 98% 40 decrease 9 46 * Cases per 10,000 patient days = minimal concerns: actual is meeting target and/or below benchmark; = concern area: actual is either not meeting target or not below benchmark or data points moving in negative direction; = problem area: actual is not meeting target and/or above benchmark. Under the leadership of Dr. Andrew Webb, Vice President, Medicine and Dr. Elizabeth Brodkin, Infection Prevention and Control (IPC) Executive Medical Director, the IPC program at Fraser Health (FH) is very pleased to present the 2013/2014 annual report. IPC is a corporate program that supports FH in the achievement of excellence in healthcare through implementation of infection prevention and control evidence based best practices. In an effort to meet the FH high priority initiative of improving patient safety by strengthening infection prevention and control, the IPC team focused on a number of very important initiatives and major projects for 2013/2014 as highlighted in the following pages. This report identifies the accomplishments of the program, illustrates the diverse scope of IPC initiatives across FH and outlines major goals and priorities for the 2014/2015 fiscal year. Annual Report: Page 1

6 In a healthcare environment where accountability and transparency is at the centre of garnering public trust, IPC at FH welcomes your feedback on this report. IPC Manual One high priority for the IPC program in 2013/2014 was to develop an inclusive IPC manual to guide evidence based best practices. The IPC program developed approximately 30 new documents for use by staff and physicians including new clinical practice guidelines, standard operating procedures, clinical decision support tools and a comprehensive (A Z) table that identifies IPC requirements and best practices for managing infectious organisms and their associated conditions. Part of the updated manual includes the GI policy and clinical practice guidelines, hand hygiene policy and clinical practice guideline, as well as fact sheets and education material for the emerging Multi drug Resistant organisms (MDROs), particularly, Carbapenem producing Enterobacteriaceae (CPE). HAI Surveillance Two additional priorities for this fiscal year were the continued focus on reducing healthcare associated infections (HAI) including cases of Clostridium difficile infection (CDI) and meeting the challenges of addressing and controlling a new emerging pathogen, Carbapenemase producing Gram negative bacteria. Surveillance is a key component of the IPC program used to monitor emerging issues and guide improvement initiatives. One focus for 2013/2014 was to improve CDI surveillance and reporting through development and deployment of an automated CDI surveillance system. Another area of focus pertained to development of an automated surveillance and data capture system for all antibiotic resistant organisms (AROs) and multidrug resistant organisms (MDROs), including CPE. CDI FH continued to focus on CDI reduction and improvement initiatives for 2013/2014. Strategies from 2012/2013 are embedded into front line practice, including individual GI case, alert level and outbreak level cleaning, use of the Bristol Stool Chart, decluttering activities and hand hygiene. Additional improvement strategies for 2013/2014 included a root cause analysis review of all nosocomial CDI cases using IPC Nosocomial CDI Risk Assessment and CDI Case Management Tools identifying units most vulnerable to CDI transmission; and, reporting adverse CDI outcomes (toxic megacolon, colectomy Annual Report: Page 2

7 and death) in the Patient Safety Learning System for unit follow up and review. CDI incidence rates decreased 44% from 7.3 cases per 10,000 patient days in 2012/2013 to 4.1 cases per 10,000 patient days in 2013/2014. Carbapenemase-Producing Enterobacteriaceae (CPE) Despite MDROs being relatively common in a number of countries around the world, they are recently emerging as a concern for healthcare facilities in BC, particularly the Carbapenemase producing Enterobacteriaceae (CPEs). Travelers who have been admitted to hospitals in endemic countries may become colonized with these bacteria and bring them into our facilities. Infections caused by CPE are very difficult to treat as they are highly resistant to a most antibiotics, including carbapenems, antibiotics of last resort. Hospitals across BC (including in FH), in collaboration with the Provincial Health Services Public Health Laboratory in Vancouver, have been screening and testing for CPE in an effort to ensure colonized patients are identified and these bacteria are not transmitted from patient to patient. FH identified 63 CPE cases in 2013/2014 with one outbreak declared in February (BCCDC Carbapenemase Producing Organisms (CPO) Fact Sheet). Rigorous attention to IPC best practices such as placing colonized patients in a private room, dedicated medical equipment, meticulous attention to hand hygiene and protective personal equipment are essential for preventing transmission from patient to patient. MRSA The improvements undertaken for HAI reduction and management of CDI, and CPE, along with hand hygiene improvements also contributed to a small decrease in the rate of Methicillin Resistant Staphyloccocus aureus (MRSA) across the organization from 5.7 cases per 10,000 patient days in 2012/2013 to 5.0 cases per 10,000 patient days in 2013/2014. Hand Hygiene The FH hand hygiene program continues to grow and expand across the organization with gradual improvements in hand hygiene compliance by all healthcare professionals; this is important as hand hygiene compliance is a fundamental component of all FH HAI reduction strategies. As part of an engagement strategy to facilitate awareness and improvement, hand hygiene audits are conducted across all facilities throughout FH including all acute care units, FH operated residential facilities Annual Report: Page 3

8 and many outpatient clinics. Hand hygiene compliance increased by 9% from 72% in 2012/2013 to 79% in 2013/2014. FH installed approximately 40,000 new hand hygiene dispensers and products at point of care and at the entrance to each patient or treatment room across the continuum of care from acute care units to home health and community programs. This improvement may have contributed to the observed increase in hand hygiene compliance due to improved access for staff. Hand hygiene audit observations increased from 104,597 observations in 2012/2013 to 108,421 in 2013/2014, reflecting increased engagement in the auditing and improvement process. Reprocessing FH completed required BC Ministry of Health (MoH) reprocessing audits and implemented a series of regional reprocessing polices and remediation activities, including Standard Operating Procedures (SOPs) and education material to guide the reprocessing of patient care equipment and medical devices. The organization will continue to monitor reprocessing practices through cyclical audits of programs and reporting of gaps through program quality committees that report to the FH Quality Performance Committee (QPC).The number of audits conducted by IPC increased for 2013/2014 and compliance rates reflected an increase in compliance to best practice requirements. Outbreak Management As part of the effort to decrease CDI incidence rates across the organization, a rigorous GI policy with clinical practice guidelines for management of all GI (gastrointestinal) cases and outbreaks was fully implemented. These protocols mandate the escalation of IPC initiatives depending on the number and prevalence of GI cases on a unit and the deployment of a rapid response Outbreak Management Team (OMT) when an outbreak is declared. Communication s and alerts are distributed daily to affected stakeholders with key IPC practice reminders for all staff. Information about outbreaks is posted at the site and on the FH public website. FH decreased the number of CDI outbreaks in 2013/2014 compared with 2012/2013 from 14 to 9. Tuberculosis (TB) In September 2013 the Fraser Health TB Coordinating Committee was formed, with representatives from Public Health, Infection Prevention and Control, and Workplace Health. This committee meets weekly and is now responsible for directing all contact Annual Report: Page 4

9 tracing around infectious TB cases, including patient and staff contacts in our facilities and contacts in the community. (Previously, TB Control at BCCDC was directing the follow up of clients exposed to infected patients although the actual follow up was carried out by FH staff.) Three Medical Health Officers provide medical oversight and direction to the nurses in each program who conduct the follow up. Surveillance of contact tracing activities will be captured in a database presently under construction by Health and Business Analytics under the guidance of the IPC program and Public Health at FH. Education Another priority for the IPC team is to provide education to staff, physicians, patients and visitors on infection prevention and control best practices. Education takes many forms, from didactic classroom education to individual just in time instruction with patients and visitors including unit safety huddles and train the trainer sessions. Education was provided this year for staff, patients, clients, visitors, physicians and volunteers on topics ranging from new employee education, routine practices and additional precautions, hand hygiene principles, audits and improvement work, GI infection including CDI, individual case and outbreak management, decluttering and communicable diseases such as measles and TB. Key Priorities 2014/2015 Based on 2013/2014 initiatives and accomplishments, the key priorities for next year will be: Publish new IPC manual and A Z table; develop and implement education plan Surveillance and reduction of healthcare associated infections: CDI, MRSA, CPE and Central Line Associated Bloodstream Infections Engagement strategies and continued improvement for hand hygiene compliance Implementation of the automated reprocessing audit platform and QA framework Strengthen Antimicrobial Stewardship across FH Complete the business case and secure funding for the GeneXpert testing platform Ensure strong medical governance for FH IPC program Annual Report: Page 5

10 Introduction The Fraser Health (FH) Infection Prevention and Control (IPC) program s mandate is to ensure patient, resident, client, staff, physician, and visitor safety through control and prevention of infectious agents across the continuum of care. In fiscal year 2013/14, the IPC program continued to expand; filling IPC Practitioner vacancies at FH sites, expanding and hiring additional IPC Consultants in the community and acute care, along with continued development of the IPC Operations and Clinical Program roles and responsibilities. IPC has a regional structure that provides consultation across FH programs as well as providing local operational support at each of the acute care sites. The IPC team provides expertise in infection prevention and control principles, best practices, and standards that promote patient safety efforts across FH from front line to organizational levels. The IPC program also participates in expert committees and collaborates with other BC health authorities, as well as local, provincial, and national quality and patient safety organizations and related initiatives. A selection of organizations that IPC works in partnership with includes the Provincial Infection Control Network (PICNet), Infection Prevention and Control (IPAC) Canada and BC Chapter, the BC Patient Safety and Quality Council, Accreditation Canada, the Provincial Hand Hygiene Working Groups and the Reprocessing Working Groups. The program also works in concert with the BC Ministry of Health in developing Best Practice Guidelines (hand hygiene, Reprocessing, Environmental Services). Infection prevention and control across the organization is accomplished by: Undertaking surveillance, trending, and reporting of site and program based healthcare associated infections (HAI) to increase awareness and response of patient safety issues and help drive improvement initiatives Engaging stakeholders in the adoption, implementation and standardization of IPC principles and best practices Educating and partnering with employees, physicians, third party providers, patients, clients, residents, visitors and volunteers Strategic initiatives and improvement actions for fiscal year 2013/2014 were comprised of the following categories: Development of the IPC manual, standards and best practices Annual Report: Page 6

11 Management and surveillance of Carbapenemase producing Enterobacteriaceae (CPE) Reduction and improvement initiatives for HAIs Development of automated databases and reporting systems for CDI and new MDRO surveillance Comprehensive and timely reports, and improvement initiatives for hand hygiene audits and CDI units that are vulnerable to CDI transmission Reporting and accountability to MoH, the public and FH organization Formalization of the IPC medical governance structure with hiring of Medical Microbiologists into the Head of Department (local) positions for FH acute care facilities IPC professional development and education Development and implementation of construction standards IPC standardization of purchasing and procurement through participation in RFPs Conducting MoH reprocessing audits, dissemination of reports and providing support for remediation work Details are available throughout the body of the annual report. The FH IPC program reports to Dr. Andrew Webb, the Vice President Medicine, who provides executive leadership and strategic oversight for clinical care quality and patient safety. The IPC program is led by an Executive Medical Director and an IPC Strategy and Performance Director, with consultation from the Medical Microbiologists/ Pathologists from the Department of Laboratory Medicine and Pathology, Public Health, Workplace Health, and numerous other programs across the Health Authority(see Appendix A for IPC Program Chart). The IPC Annual Report is organized in three sections: Executive Summary and Introduction Healthcare Associated Infection (HAI) Indicators Surveillance Best Practice Annual Report: Page 7

12 Infection Prevention and Control Program IPC Leadership Dr. Andrew Webb Vice President, Medicine Dr. Elizabeth Brodkin IPC Executive Medical Director Petra Welsh Director, IPC Strategy and Performance Sandra Daniels/ Catherine O Donnell / Rene Pitts IPC Managing Consultants/Manager Tara Leigh Donovan Epidemiologist Sergio Pastrana & Loretta Bogert O Brien Health Data Analyst Lindsay MacDonald and Tiffany Fabro Strategic Transformation Support Julie Reynolds Administrative Assistant Infection Prevention and Control Practitioners and Consultants (alphabetical order by surname)* IPC Practitioners Abed, Vlada Gara, Aleksandra Page, Michelle Au, Stephanie Garcha, Shelly Panesar, Parm Baddan, Sandeep Giesbrecht, Amanda Ratzlaff, Jackie Bleackley, Pat Imamovic Bul, Amira Riarh, Kam Bos, Stephanie Jensen, Karen Rodgers, Karen Butler Lim, Susan Johal, Rani Schall, Valerie Chan, Daniel Kim, Lauren Sohi, Raj Chilton, Kathy McLean, Rhonda Tjosvold, Sandra Dhaliwal, Parveen Mendes, Adriana Verbeck, Jan Dickson, Terry Nelson, Tanis Wong, Winnie Emley, Kirsten Nichols, Janie IPC Consultants Brierton Joseph, Iona Hlagi, Jacqueline Parent, Sharon Chisholm, Paul Ibrahimov, Fuad Reimer, Lisa Esmail, Noorsallah O Donnell, Catherine Taha, Fatma Espezel, Hilary Ormond, Sarah Annual Report: Page 8

13 *The IPC Practitioners report to the Director Site of Operations for the facility they work in. This list depicts all staff that was part of the program during the 2013/2014 reporting period. The IPC Consultants report through the IPC Managing Consultants to the Director, IPC Performance and Strategy. Acknowledgements The IPC program would like to acknowledge the important partnerships shared with clinical support teams and the significant contribution they provide in achieving positive results for the infection prevention and control initiatives across the organization. Included in this acknowledgement are the FH Executive Team, Medial Microbiologists, Medical Program Directors, Physicians, Executive Directors, Site Directors, Clinical program Directors and managers and all FH program staff. We look forward to continued collaboration to address those areas where nosocomial infections continue to have a negative impact on patients and their families.it is a privilege to work with dedicated, compassionate, and knowledgeable staff throughout the organization. Special thanks go to: BC Centre for Disease Control BC Public Health Microbiology and Reference Lab BC Patient Safety and Quality Council Colleagues from other provincial health authority IPC programs Communications and Public Affairs Community and Hospital Infection Control Association (CHICA) Canada and CHICA BC Crede Technologies Health & Business Analytics BISS and General Managers of P3 facilities and all Environmental Services staff Facilities Maintenance & Operations Health Promotion and Prevention Health Shared Services BC Information Management Integrated Risk Management Annual Report: Page 9

14 Medical Health Officers Ministry of Health Services Pharmacy Services Population Health Assessment Team Provincial Infection Control Network (PICNet) of BC Quality Improvement & Patient Safety Workplace Health & Safety Annual Report: Page 10

15 Healthcare Associated Infection (HAI) Indicators Clostridium difficile Infection (CDI) Clostridium difficile infection (CDI) is one of the most commonly acquired healthcareassociated infections (HAIs) in industrial countries. CDI is often related to antimicrobial therapy, which alters the normal bacteria found in the gastrointestinal tract. CDI may be a mild infection or can present as massive diarrhea that may be difficult to control, with the potential for toxic megacolon, sepsis, and even death. Key Definitions: Facility associated CDI incidence rate (for sites and FH overall) [Number of new CDImost likely acquired and confirmed/diagnosed at the same site divided by total patient days for particular site or FH overall] * 10,000 (Note: does not account for cases that are transferred between sites) Healthcare associated CDI incidence rate (for programs) [Number of new CDI likely associated with an FH program divided by total patient days for particular program] * 10,000 Status Improvement Reduction in rate Target <6.0 per 10,000 patient days Actual (2013/2014) 4.1 per 10,000 patient days Annual Report: Page 11

16 Figure 1: Number of new CDI and facility associated CDI incidence rate per 10,000 patient days by fiscal year for FH Figure 2: Number of new CDI and healthcare associated CDI incidence rate by FH program, 2013/2014 Annual Report: Page 12

17 Methodology Figure 3: Number of new CDI and healthcare associated CDI incidence rate by FH program, 2013/2014 CDI case identification and confirmation is completed by the IPC Practitioners using a provincial standardized case definition and protocol to identify cases from medical microbiology reports, admission reports, and chart reviews. IPC Practitioners enter relevant, clinical details into an internal FH database that contains automated, electronic lab confirmation of C.difficile test results, combined with healthcare related admission information that pertains to the FH patient. Patients diagnosed with CDI during surgery or scope procedures are manually entered into the database. The IPC health data analyst extracts and analyzes the data and the epidemiologist provides interpretation and explanation of the findings and oversees the surveillance program. The case definition of CDI is met when any of the following criteria apply among admitted patients: 1. Laboratory confirmation by positive toxin PLUS a. acute onset of diarrhea* above what is normal for the individual and cannot be attributed to another cause (e.g., laxatives, medication side effect, diet, or medical condition) OR Annual Report: Page 13

18 b. diagnosis of toxic megacolon OR 2. Diagnosis of pseudomembranous colitis on sigmoidoscopy, colonoscopy, or histological/pathological diagnosis of CDI *defined as 3 or more unexplained liquid stools (that take the shape of the container / Bristol Stool Chart 6 7) that continue for a minimum of 24 hours Surveillance includes tracking and review of: A case as defined above, occurring more than three calendar days (>72 hours) after admission, OR A case with symptom onset in the community or 72 hours or less after admission (minimum 24 hrs) to a healthcare facility, provided that symptom onset was less than four weeks after the last discharge from a healthcare facility, AND If patient was a previously confirmed case, the current symptom onset is more than 8 weeks from the previous resolution or discharge date Note: Infection with Clostridium difficile causes severe colitis with severe diarrhea. A positive lab result alone does not indicate an active infection that requires treatment; it may indicate colonization. Inclusion criteria: all newly confirmed healthcare associated cases of CDI among admitted acute care patients. Exclusion criteria: outpatients, residential care patients/residents, children less than one year of age, and relapses. New case of CDI A CDI case without previous history of CDI, OR A CDI case that has not had an episode of CDI in the last eight weeks Relapse of CDI A confirmed case that meets case definition and experiences a recurrence of diarrhea within 8 weeks of the resolution date (or discharge date if resolution date is not available) of the last CDI related diarrhea (i.e. returned to usual bowel habits). What is the Annual Target the organization seeks to reach? A CDI incidence rate of 6.0 cases per 10,000 inpatient days was the established target for FH for 2013/2014 fiscal year, which closely reflects the 2012 Canadian Nosocomial Annual Report: Page 14

19 Infection Surveillance Program (CNISP)overall facility associated CDI rate of 6.04 per 10,000 inpatient days[antimicrobial resistant organisms (ARO) surveillance. CNISP (February 2014)].The stretch target of 6.0 per 10,000 patient days was chosen because of various targeted CDI reduction strategies implemented during fiscal 2013/2014. The FH rate of new cases of CDI for 2013/2014 was 4.1cases per 10,000 patient days which was below the target. Benchmark Comparison: How does the rate compare to other areas? The provincial rate of new cases of CDI associated with the reporting facility is used as a benchmark for FH due to a similar methodology and reporting structure. The provincial annual CDI rate was 6.5 per 10,000 inpatient days [95% CI: ] in fiscal year 2012/2013 which is the most recently published provincial annual rate. The 2013/2014 annual rate of CDI for FH of 4.1 per 10,000 inpatient days [95%CI: ] was significantly below the provincial 2012/2013benchmark [Clostridium difficile infection (CDI) surveillance report for fiscal year 2012/2013. Provincial Infection Control Network of BC (2013). Retrieved from pdf]. Trend: What does the data show? Overall FH The FH facility associated incidence rate was 4.1 per 10,000 patient days [95% CI: ] in fiscal year 2013/2014, which is the lowest fiscal year rate in the past 9 years and represents a statistically significant decrease from the previous fiscal year rate of 7.3 per 10,000 patient days [95% CI = ] in 2012/2013 (Figure 1). The CDI incidence rate decreased 44% from 2012/2013 to 2013/2014. The proportion of new CDI that were community associated in fiscal year 2013/2014 was 25%, compared to 28% in fiscal year 2012/2013. FH Acute Care Sites In 2013/2014, the CDI incidence rate was highest among MMH, BH and RCH (Figure 2). The CDI incidence rates among FH sites ranged from zero at FCH and MSA to 6.3 per 10,000 patient days (9 new CDI) at MMH (Figure 2). It is important to note that MMH had a small number of new CDI (9 new CDI) but the highest rate as a result of the small size of this site and therefore a small number of patient days (i.e. denominator) compared to larger sites. FCH and MSA are small community hospitals that typically Annual Report: Page 15

20 handle patients with lower acuity as opposed to tertiary care centers in FH. BH had a slightly higher CDI rate (5.3 per 10,000 patient days) compared to RCH (5.2 per 10,000 patient days) but RCH and SMH had the greatest number at 84 and 79 new CDI respectively, compared to BH with only 64 new CDI. Rationale for the higher incidence of CDI at these sites compared to other FH sites could be the result of frequent congestion and over capacity as well as the fact that these sites serve patients with higher acuity who likely experience comorbidities, health complications and critical illnesses and require antibiotic therapy which can pose an increased risk of CDI. Older infrastructure challenges at these sites can also present a challenge for implementing infection prevention and control best practices. FH Acute Care Programs In 2013/2014, the incidence rate was highest among the Older Adult and Medicine programs (Figure 3); 10.7 per 10,000 patient days (50 new CDI) and 6.8 per 10,000 patient days (246 new CDI) respectively. These two clinical programs care for the elderly and/or patients with comorbidities who may require antibiotics during their hospitalization. Older age and antibiotic exposure are known risk factors for acquisition of CDI, which may explain the higher rates among these programs. Limitations: What might have affected the quality if this measure? Caution must be taken when interpreting rates because one case can display an inflated rate for facilities and programs with a small number of beds and patient days (e.g., MMH). An increase of one or two cases can impose a high facility rate (see Appendix B for FH acute care bed numbers for fiscal year end 2013/2014). Additionally, Clostridium difficile testing practices and case definition application have varied over the years or across sites and programs, and case management as well as targeted intervention strategies have been implemented which will affect the rates. Provincial standardization of the definition for prior admission to a healthcare facility implemented April 1 st 2013, may result in an increase in the number of FH healthcareassociated cases. The duration of admission to a healthcare facility was set to a minimum 24 hours when determining if a patient had an encounter to a healthcare facility within the last four weeks before current hospitalization (constitutes part of the definition for healthcare associated compared to community associated cases). Previously, the timeframe ranged from overnight to 72 hours. Annual Report: Page 16

21 In addition, a resolution date became a requirement for CDI cases as part of a modified relapse definition in FH, introduced in July Resolution date is the date after 72 hrs has passed since last diarrheal stool or stool returns to normal for patient (e.g. May 1 last liquid stool, May 2 24hrs, May 3 48hr, May 4 72hrs. Resolution date is May 4) [Note: discharge date is used in lieu if resolution date is unknown or unattainable.] A relapse is a confirmed case that meets case definition and experiences a recurrence of diarrhea within 8 weeks of the resolution date (or discharge date if resolution date is not available) of the last CDI related diarrhea (i.e. returned to usual bowel habits). Previously, a relapse occurred when a CDI patient had a recurrence of diarrhea within 2 to 8 weeks of a previous C.difficile infection commencing (as determined by the date of a previous lab test, chart note or diagnosis by endoscopy or pathological specimen). The modification to the relapse definition may increase the number of relapses identified and in turn decrease the number of reinfections (i.e. new CDI cases) counted. Finally, outpatients with C.difficile that meet case definition and are subsequently admitted to acute care directly from their outpatient visit are included in the population under surveillance. This change may slightly increase the total number of CDI cases in FH. FH laboratories introduced Polymerase Chain Reduction (PCR) testing methods for CDI stool samples in fiscal year 2011/2012. Compared to the previous cytotoxicity assay, the PCR test is more sensitive and has a reduced turn around time; therefore, the numbers of reported positive cases likely increased and may be evident in the CDI statistics reported. Fraser South sites (DH, LMH, PAH, and SMH) implemented PCR testing on October 27, The remaining sites in Fraser North and East implemented PCR testing on March 19, The timeframe for evaluating the healthcare history of a patient with CDI changed from 8 weeks to 4 weeks in fiscal year 2010/2011. Cases with symptom onset in the community of 3 days or less after admission to an acute care facility, are deemed healthcare associated to that facility if the patient had a healthcare encounter in the previous 4 weeks (as opposed to 8 weeks previously). This change may decrease the number of healthcare associated CDI because the time frame for the look back period is shorter. The IPC program continues to strive for standardization with accurate and effective application of infection prevention and control practices and definitions across FH. Data Annual Report: Page 17

22 are updated and scrutinized on a regular basis and as a result, numbers and rates may slightly change from previous reports based on case updates. CDI Reduction Strategies Nosocomial CDI Risk Assessment and Case Management review of each health care associated CDI case: Commencing in July 2013, as part of an effort to improve patient safety through a better understanding of the particular factors that caused an individual patient to develop CDI, Nosocomial CDI Risk Assessment and Case Management forms were developed and implemented for healthcare associated CDI that are deemed likely attributed to a site and unit (Appendix C). These forms enable the unit to evaluate patient care factors and to identify gaps in infection prevention and control best practices, in an effort to implement improvement actions. After a two month transition period, case report forms that were completed by IPC practitioners from September 1, 2013 to February 28, 2014, identified thematic concerns for nosocomial CDI cases. The final assessments concluded that pharmacology (i.e. antibiotic exposure prior to acquiring CDI or the treatment regimen after CDI diagnosis) was the most problematic factor for nosocomial CDI, followed by underlying medical conditions of patients, enhanced cleaning of equipment and hand hygiene practices on units where patients are located both before and after CDI diagnosis. CDI adverse events and PSLS: On October 1, 2014, as part of efforts to prevent additional healthcare associated C. Difficile cases, severe (Level 4) and death (Level 5) CDI events are entered by IPC Practitioners into Patient Safety & Learning System (PSLS). Level 4 (Severe Harm) includes health care associated CDI with toxic megacolon/ colectomy and Level 5 includes death related to health care associated CDI. Entering these events into PSLS follows the FH policy to ensure that patients who experience significant harm events while receiving care in FH facilities are reviewed and actioned in an appropriate, timely manner. The review is supported by the IPC Nosocomial CDI Risk Assessment and CDI Case Management forms. The unit manager is assigned as the handler with clinical programs following up on the events as per the current PSLS process. CDI Vulnerable Unit List: Due to the excellent enhancements of the FH CDI surveillance system, FH is able to provide the organization with a list of approximately twenty units across FH that have the highest CDI incidence rates each fiscal period. The list is produced and disseminated to FH stakeholders every fiscal period in an effort to focus attention and improvement work on units in FH with the greatest burden of CDI Annual Report: Page 18

23 cases, and to support units with chronic CDI issues that are vulnerable to nosocomial C.difficile transmission. This CDI Vulnerable Unit List contains fiscal period and year todate CDI incidence rates and case counts along with hand hygiene compliance for each particular unit. Continued focus on these three CDI risk reduction strategies, (Vulnerable Unit List, Nosocomial CDI Case management and CDI Risk Assessment forms, and entry of adverse events into PSLS) each fiscal period has been very effective in focusing the organization leadership on units with chronic CDI issues. These strategies have generated significant improvement actions including soiled utility room re design, hand hygiene improvements and special task groups in an effort to reduce CDI rates on units and within programs. The Older Adult Program was so successful in reducing CDI rates on one of their units that they were awarded a second place finish by their peers for a BC Patient Safety Quality Council quality award. Areas of focus for 2014/2015 continue to be management of CDI on units vulnerable to CDI transmission through antimicrobial stewardship, continued education and awareness of infection prevention and control principles and best practices, hand hygiene compliance for staff, physicians, patients and visitors, dedicated toileting facilities, bed accommodation and cleaning of medical devices. Comments Many other factors that contribute to the transmission of CDI include workload of staff, non availability of single patient or isolation rooms in a facility, poor hand hygiene practices and/or compliance, previous prolonged or unnecessary antibiotic treatment, poor and/or infrequent environmental cleaning practices, inappropriate or delayed application of additional precautions, low availability of hand washing sinks in patient rooms, poor practice or minimal availability and sub optimal practice with respect to closed human waste disposal systems, and soiled utility rooms that do not meet infection prevention and control standards. FH strives for infection prevention and controls best practices to promote patient safety and is working to reduce the factors that contribute to patient acquisition of CDI. Methicillin-Resistant Staphylococcus aureus(mrsa) 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 Annual Report: Page 19

24 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. Key Definitions: Facility associated MRSA incidence rate (for sites and FH overall) [Number of new MRSA most likely acquired and confirmed/diagnosed at the same site divided by total patient days for particular site or FH overall] * 10,000 (does not account for cases that are transferred between sites) Healthcare associated MRSA incidence rate (for programs) [Number of new MRSA likely associated with an FH program divided by total patient days for particular program] * 10,000 Status Improvement Reduction in rate Target <7.0 per 10,000 patient days Actual (2013/2014) 5.0 per 10,000 patient days Figure 4: Number of new MRSA and facility associated MRSA incidence rate per 10,000 patient days by fiscal year for FH Annual Report: Page 20

25 Figure 5: Number of new MRSA and facility associated MRSA incidence rate by FH site, 2013/2014 Figure 6: Number of new MRSA and facility associated MRSA incidence rate by FH program, 2013/2014 Annual Report: Page 21

26 Methodology MRSA (colonization or infection) case identification and confirmation is completed by the IPC Practitioners using a standardized case definition to identify cases from medical microbiology reports. IPC Practitioners enter all cases into an internal FH database. The IPC health data analyst extracts and analyzes the data, and the epidemiologist provides interpretation and oversees the surveillance program. An MRSA case is defined as meeting ALL of the following criteria: Laboratory identification of MRSA: Staphylococcus aureus cultured from a clinical or screening specimen that 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 Surveillance includes: A case defined above occurring more than three calendar days (> 72 hours) after admission AND the infection or colonization was not present on admission OR A case defined above and the patient was admitted (minimum 24 hours) to a healthcare facility within the last 12 months. Inclusion criteria: any newly confirmed healthcare associated cases of MRSA infections or colonizations among admitted acute care patients for the first time ever. Exclusion criteria: outpatients, residential care patients/residents. What is the Annual Target the organization seeks to reach? The FH MRSA incidence rate target for 2013/2014 was 7.0 cases per 10,000 patient days, based on both the historical MRSA rates for FH and the Canadian Nosocomial Infection Surveillance Program (CNISP) 2012 overall facility associated MRSA rate (infections + colonizations) of cases per 10,000 patient days [Antimicrobial resistant organisms (ARO) surveillance. CNISP (February 2014)]. The FH rate of new MRSA for 2013/2014 was 5.0cases per 10,000 patient days, well below the target. Benchmark Comparison: How does the rate compare to other areas? The provincial rate of new cases of MRSA associated with the reporting facility is used as a benchmark for FH because of similar methodology and reporting between FH and the province. The provincial fiscal annual MRSA rate was 5.1 per 10,000 patient days [95%CI: ] in 2012/2013 which is the most recently published provincial annual Annual Report: Page 22

27 rate [Methicillin resistant Staphylococcus aureus (MRSA) surveillance report for fiscal year 2012/2013. Provincial Infection Control Network of BC (September 2013). Retrieved from pdf]. The 2013/2014 annual rate of MRSA for FH was 5.0 cases per 10,000 patient days [95% CI: ] which was slightly lower than the provincial 2012/2013 benchmark. Trend: What does the data show? Overall FH In fiscal year 2013/2014, the FH facility associated incidence rate was 5.0 cases per 10,000 patient days [95%CI: ] which was not as low as the MRSA incidence rate of 4.7 cases per 10,000 patient days in fiscal years 2010/2011 and 2011/2012 (Figure 4). The incidence rate in 2013/2014 is not statistically significantly lower than fiscal year 2012/2013 incidence rate of 5.8 cases per 10,000 patient days [95% CI: ]. The MRSA incidence rate decreased 14% from 2012/2013 to 2013/2014. FH Acute Care Sites In 2013/2014, the MRSA incidence rate was highest among RMH, SMH, and ERH respectively (Figure 5). The MRSA incidence rates among FH sites ranged from zero at FCH to 10.0 cases per 10,000 patient days (70 new MRSA) at RMH (Figure 5). FCH is a small community hospital compared to a tertiary care centre in FH. The smaller sites have fewer beds and fewer patients, potentially lowering the risk of transmission and acquisition of MRSA. Among FH acute care sites, SMH and RCH had the greatest number of new MRSA cases with 137 and 86 respectively (Figure 5). The higher number of cases could be the result of frequent congestion and over capacity issues as well as infrastructure challenges at these sites which can impact the ability to consistently adhere to infection prevention and control best practices. FH Acute Care Programs In 2013/2014, the MRSA incidence rate was highest among the Medicine and Rehab programs (Figure 6); 8.9 cases per 10,000 patient days (323 new MRSA) and 8.5 cases per 10,000 patient days (61 new MRSA) respectively. These two clinical programs care for patients with comorbidities who may require antibiotics during their hospitalization and typically have a longer length of stay compared to other clinical areas. Further, rehab patients often participate in group activities which may increase the likelihood of transmission of MRSA. Antibiotic exposure is a known risk factor for acquisition of Annual Report: Page 23

28 MRSA, which may explain the higher rates among these programs. In addition to the high number of new MRSA associated with the Medicine program, the Surgery program had 116 new MRSA in 2013/2014 (Figure 6). Limitations: What may have affected the quality of this measure? Caution must be taken when interpreting rates because one case can display an inflated rate for facilities and programs with a small number of beds and patient days (i.e. denominator). An increase of one or two cases can result in an inflated MRSA rate (see Appendix Bfor FH acute care bed number for fiscal year end 2013/2014). Additionally, case definition application has varied over the years and/or across sites and programs, and case management as well as targeted intervention strategies have been implemented which will affect the rates. Beginning April 1, 2013 (i.e. start date of fiscal year 2013/2014), the duration of admission to a healthcare facility was standardized provincially at a minimum 24 hours when considering if a patient had an encounter to a healthcare facility within the previous 12 months. Previously, no explicit timeframe was indicated and ranged from overnight to 72 hours. This change in admission duration could increase the number of FH healthcare associated compared to community associated cases. Starting in October 2013, outpatients identified with MRSA were considered incidence cases of MRSA which differs from prior years where only inpatients with MRSA were captured. Because the population under surveillance excludes outpatients with MRSA, this change could decrease the total number of new MRSA identified and reported in FH. Classification of healthcare associated MRSA cases, using a 12 month look back period, is time consuming and requires chart review, which may not always be feasible, and records may not be complete or available. Data collection only includes first incidence of MRSA, whether it be a colonization or infection. Colonizations that develop into infections are not captured; therefore, an accurate number of colonizations and infections and corresponding rates for FH are not possible. Screening practices as well as isolation and contact precautions among cases may have varied over the years or across sites and programs, thus affecting the rates. The IPC program continues to encourage standardization and accurate and effective application of infection prevention and control practices and definitions across FH. Data are Annual Report: Page 24

29 updated and scrutinized on a regular basis and as a result, numbers may slightly change based on case updates. MRSA Reduction Strategies The improvements undertaken for HAI reduction and management related to CDI, CPEs and outbreaks, along with hand hygiene compliance improvements all contribute to the small reduction in MRSA rates for 2013/2014. The details of these improvement actions can be found under the related sections within this report. Areas of focus for 2014/2015 are similar to management of CDI with respect to antimicrobial stewardship, continued education and awareness of IPC principles and best practices, and hand hygiene compliance and improvements for staff, physicians, patients and visitors. Comments Known factors that contribute to the transmission of MRSA include poor hand hygiene practices, longer duration from MRSA identification to initiation of additional precautions, unavailable single patient or isolation rooms in a facility, and incomplete and/or infrequent environmental cleaning practices. FH strives for infection prevention and controls best practices and patient safety and aims to reduce the factors that contribute to patient acquisition of MRSA. Carbapenemase-Producing Enterobacteriaceae (CPE) Enterobacteriaceae are Gram negative bacteria, which commonly colonize the human gastrointestinal tract. Examples include Klebsiella, and Enterobacter species. There is potential for infection when any of these organisms move from the GI tract into other body spaces, for example wounds, bladder, respiratory tract or bloodstream. The environment can become contaminated with these organisms, providing another source of spread. Carbapenems are a family of antibiotics used to treat serious infections caused by gram negative bacteria that are resistant to other antibiotics. However, some Enterobacteriaceae are naturally resistant to Carbapenem antibiotics and others develop resistance through changes to the outer membrane of the bacteria (these known as Carbapenem resistant Enterobacteriaceae [CRE]). Others become resistant through the production of enzymes encoded for by resistance genes that destroy Carbapenems, and are known as Carbapenemase producing enterobacteriaceae [CPE]). The resistance genes can transfer between bacteria by means of plasmids. When Enterobacteriaceae Annual Report: Page 25

30 resistant to Carbapenems cause infections, there are few treatment choices available. Carbapenem resistant bacteria have become common in some parts of the world, and patients who travel to those areas may return home colonized with CPE, particularly if they were hospitalized while there. When colonized patients enter FH hospitals there is a risk they will spread the bacteria to other patients. In order to identify colonized patients and prevent transmission to others, FH has undertaken an active screening and surveillance program for early detection and management of cases. Table 1: CPE in FH, 2013/2014 Infections Colonizations Total New CPE 18 (29%) 45 (71%) 63 Methodology CPE (colonization or infection) identification is carried out by the IPC Practitioners based on laboratory confirmation from medical microbiology reports. IPC Practitioners enter epidemiologic and clinical details into an internal FH database. The IPC epidemiologist extracts and analyzes the data and provides interpretation and explanation of the findings and oversees the surveillance program. A CPE case is defined by the following criteria: Laboratory identification of CPE: Carbapenemase producing enterobacteriaceae (CPE) screening is done using a selective culture based assay with confirmatory susceptibility and phenotypic testing. Molecular confirmation is performed at the British Columbia Public Health Microbiology and Reference Laboratory (BCPHMRL), Vancouver, or the National Microbiology Laboratory (NML), Winnipeg Surveillance includes: A CPE case that is admitted to an acute care facility or receiving dialysis and is confirmed to have a Carbapenemase producing Enterobacteriaecae, for the first time it is detected only. Inclusion criteria: admitted acute care patients or renal patients identified to have CPE for the first time. Exclusion criteria: patients who were previously positive, outpatients (e.g. ER visits, IV therapy clinic visits, etc.), and residential care patients/residents. Annual Report: Page 26

31 Screening Protocol Fraser Health implemented a CPE screening process in 2014 for all patients admitted into FH acute care hospitals and for patients newly receiving renal dialysis treatment, for the purpose of identifying patients colonized with CPE. The screening process involves Registration asking newly admitted patients: Have you been admitted to a hospital or had renal dialysis treatment outside Canada within the last 6 months? Anyone who answers yes must be swabbed for CPE. One fecally stained rectal swab is required for testing within 24 hours of admission to an acute care FH facility. Screening provides early identification of patients colonized with CPE on admission, ensuring prompt and appropriate management, preventing transmission to other patients and staff. Screening was implemented beginning in July 2013 and was in place at all FH facilities by March FH performs screening and surveillance of this organism because CPE is an emerging pathogen and we wish to understand the epidemiology of this organism in our region and to ensure colonized patients are isolated appropriately to reduce transmission. What is the Annual Target the organization seeks to reach? CPE is an emerging organism in FH and therefore a target was not applicable for fiscal year 2013/2014. The number of cases from 2013/2014 will provide a baseline for future targets; however with increased screening it is likely that the number of cases will rise. Benchmark Comparison: How does the rate compare to other areas? CPE is a newly emerging organism and there is insufficient data to allow for benchmarking at a provincial or national level. Provincial reporting will begin next fiscal year. Trend: What does the data show? Fiscal year 2013/2014 is considered the baseline for CPE reporting in FH. The majority of cases identified were colonizations (71%) rather than infections (29%). This finding is expected because of the screening protocol that was put in place beginning in Screening captures patients who are colonized with CPE but who do not have symptoms and therefore can go undetected without active screening in place. Annual Report: Page 27

32 Limitations: What might have affected the quality if this measure? As a result of the screening protocol that was implemented beginning in 2013, there was an increased likelihood of identifying and in turn reporting CPE cases. Currently there is limited understanding of the community prevalence of CPE and the extent of transmission that is occurring in our communities. This will affect the number of CPE cases that may be identified in future. Comments FH declared an outbreak of CPE at RCH on February 3 rd The outbreak was declared because of sustained transmission on the unit despite usual control measures being in place. Specific outbreak control measures included: 1. Cohorting of patients and staff. All colonized patients were placed in private rooms with dedicated nursing. 2. Dedicated equipment for colonized patients. 3. Emphasis on hand hygiene and PPE for staff working on the unit. 4. Enhanced twice daily cleaning of the entire unit. 5. Communication with the unit, site and public. Signage and barriers were placed on the unit. 6. Declaration of the outbreak on the FH public website. 7. Weekly meetings of the Outbreak Management team, including: Site Director, Medical Microbiologists, unit staff, ancillary staff, housekeeping, other site leadership and the IPC team. 8. Detailed surveillance and reporting of all cases on the unit. 9. Admission and weekly point prevalence CPE screening for all patients on the unit. Once these control measures were put in place, transmission between patients stopped. The outbreak was declared over 6 weeks after the last case was identified. There have been no transmissions on the unit since that time. Annual Report: Page 28

33 Vancoymcin Resistant Enterococci (VRE) Enterococci are micro organisms that are commonly found in the stomach and bowels of healthy people. Vancomycin is an antibiotic used to treat infections, and some strains of Enterococci are resistant to Vancomycin. These organisms rarely cause illness in healthy people. However, on rare occasions the bacteria may move from the bowel to other body sites and cause serious infections of the blood or other body tissues. Figure 7: Number of VRE (infections and colonizations) by month and year for FH Annual Report: Page 29

34 Table 2: VRE specimen source, 2013/2014 VRE Specimen Source Grand Total Groin 4 (<1%) Rectal/perineum 8 (1%) Sputum/respiratory 8 (1%) Surgical site wound 12 (2%) Blood 35 (6%) Skin & soft tissue wound 36 (6%) Other (e.g. nephrostomy, peritoneal fluid, etc.) 41 (7%) Urine 426 (75%) Grand Total 570 Methodology VRE (colonization or infection) case identification and confirmation is carried out by the IPC Practitioners using a standardized case definition to identify cases from medical microbiology reports. IPC Practitioners enter all cases into an internal FH database. The IPC health data analyst extracts and analyzes the data, and the epidemiologist provides interpretation and oversees the surveillance program. A VRE case is defined as meeting ALL of the following criteria: Laboratory identification of VRE: Enterococcus cultured from a clinical or specimen which is vancomycin resistant by standard susceptibility testing methods or positive by molecular methods for the vana, vanb, or vanc genes is considered a vancomycin resistant Enterococcus (VRE). Surveillance includes: A case defined above occurring more than three calendar days (> 72 hours) after admission OR A case defined above and the patient was admitted (minimum 24 hours) to a healthcare facility within the last 3 months. Annual Report: Page 30

35 Inclusion criteria: any healthcare associated, confirmed VRE colonization (first time only) or infection among admitted acute care patients. Patients with both VRE colonization and infection are counted twice and patients with multiple infections from more than one source are included. All VRE bloodstream infections are counted. Exclusion criteria: outpatients, residential care patients/residents. VRE Protocol Changes VRE can spread within healthcare facilities, however for most people the bacteria does not move from the bowel to cause infection in other body sites. Until November 2012 Fraser Health had a protocol in place to screen patients and identify carriers of VRE (patients colonized in the bowel). Recognizing that few infections occurred as a result of VRE colonization, this protocol has now changed and FH has chosen to focus efforts on other antibiotic resistant organisms that do cause serious infections. FH staff no longer performs routine tests for VRE colonization and no longer apply special infection control measures to patients with VRE colonization unless the patient has a VRE related infection. However, the IPC program is monitoring clinical outcomes of patients with VRE infection to evaluate this change in protocol and ensure patients are not at increased risk as a result of the change. Surveillance reports are provided to HAMAC for accountability and evaluation. What is the Annual Target the organization seeks to reach? There was no specified FH target for VRE in 2013/2014. Benchmark Comparison: How does the rate compare to other areas? There is insufficient data to allow for benchmarking at a provincial or national level. Trend: What does the data show? There have been a total of 570 confirmed healthcare associated VRE cases since November 2012; 36% of these are colonizations and 64% are infections. There were 25 patients who had more than 1 infection from a different source that have been included in the results. Since the VRE protocol change there has been a decline in the number of colonizations reported in FH (Figure 7). This result is expected as FH is no longer searching for colonized VRE patients by screening admitted inpatients upon entry to acute care sites. The number of infections has varied over time from November 2012 to March 2014 (November 1, 2012 to March 31, 2014) with no consistent trend. FH will Annual Report: Page 31

36 continue to closely monitor VRE infection activity to evaluate the impact of the screening changes (Figure 7). The majority of confirmed VRE specimens from November 2012 to March 2014 were urine samples (75%). Six percent of all VRE infections were bloodstream infections. FH will continue to monitor bloodstream infections to ensure this proportion remains low. Limitations: What may have affected the quality of this measure? Reporting of VRE infections is impacted by the varied practices of physicians and the number of clinical isolates ordered. In October 2013 the VRE protocol was changed and a request was made for IPC practitioners to enter all VRE specimens found in inpatients for the first time as well as when status changed from colonization to infection or the source of culture for an infection changed (e.g. infection in wound to infection in blood). Multiple blood specimens for the same patient are entered if there is a new infection. This change may have caused an increase in the number of infections reported since October Beginning April 1 st 2013 (i.e. start date of fiscal year 2013/14), the duration of admission to a healthcare facility was standardized provincially to a minimum of 24 hours when considering if a patient had an encounter to a healthcare facility within the 3 months prior to the current hospitalization. Previously, no explicit timeframe was indicated and ranged from overnight to 72 hours. This change in admission duration could increase the number of cases deemed to be FH healthcare associated. Comments Linezolid Use in FH Table 3: Linezolid use FH, 2013/2014 Date # DDD* Fiscal 2011/ Nov 2012 to Feb Mar to May Jun to Aug Sep to Nov Dec 2013 to Feb Defined Daily Dose (DDD) for linezolid, 1200 mg Annual Report: Page 32

37 Surveillance of linezolid use in FH was an additional measure put in place after the VRE screening protocol was changed. This type of antibiotic is the primary treatment option for VRE infection and therefore the purpose of this measure is to understand if linezolid use has increased, presumably as a result of increasing numbers of VRE infections. Table 3indicates a positive, consistent decline in the prescription of linezolid in FH. It is important to note that there is typically seasonality associated with use of Linezolid, but overall the data indicates a decrease, particularly from the summer to fall months which is indicative of a reduction in prescribing of the drug. Annual Report: Page 33

38 Best Practice Hand Hygiene Compliance Hand hygiene is a critical patient safety initiative and one of the most effective, wellknown 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 IPC Practitioners. Through monitoring hand hygiene compliance and using continuous observational audits and on going improvement activities, FH is continuing to align with the Canadian Patient Safety Institute s Safer Healthcare Now! Initiative, and with Accreditation Canada s Required Organizational Practices, as well as the provincial auditing and reporting of hand hygiene compliance. Status Improvement Increase in compliance Target 80% compliance Actual (2013/2014) 79% compliance Table 4: Hand hygiene compliance by type of FH facility, fiscal year 2013/2014 Fiscal Year 2013/2014 FH Overall Acute Care Residential Owned & Operated Mental Health & Substance Use Home Support/ Home Health JPOCSC/ Public Health/ Primary Care Compliance 79% 79% 81% 66.5% 83% 81% Observations 108,421 91,240 10,194 2,070 1,386 3,531 Annual Report: Page 34

39 Figure 8: Comparison of hand hygiene compliance by fiscal year in FH acute care sites Figure 9: Hand hygiene compliance among all staff by FH site, 2013/2014 Annual Report: Page 35

40 (See Appendix D)for # of observations by FH program) Figure 10: Hand hygiene compliance among all staff by FH program, 2013/2014 Figure 11: Hand hygiene compliance by health care provider group for FH overall, 2013/2014 Annual Report: Page 36

41 Methodology Hand hygiene audits are an ongoing performance measure across FH. Majority of hand hygiene observations in fiscal year 2013/2014 were completed by audit trained and certified healthcare providers on units. Observations were completed in various settings including Acute Care facilities, Residential Owned and Operated facilities, Mental Health& Substance Use facilities, Outpatient settings including JPOCSC, Public Health Units, Primary Care facilities, and among Home Support and Home Health (with the exception of Residential Contracted facilities). Multiple FH programs were audited. All auditors received standardized training based on the hand hygiene audit toolkit available to all staff via the FHPulse and were certified through a practice audit by IPC Practitioners or Consultants. Auditors collected the hand hygiene observations on unitspecific audit forms that are faxed to a central provider and submitted into an electronic hand hygiene audit system (FormAudit) where it is stored on a secure server. Data are accessible to all FH staff on the FHPulse. Observations for hand hygiene compliance included before and after opportunities based on the four moments for hand hygiene. Use of both soap and water and alcohol based hand rub (ABHR) were included for compliance. Missed opportunities occurred when hand hygiene compliance was not adhered to. Each audit included a minimum of five healthcare providers who were observed up to 10 opportunities for hand hygiene; a valid audit required at least 25 total observations. 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/healthcare provider types is collated into four category codes: Nurse Physician Clinical Other NP/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, Pharmacist Housekeeping, Maintenance, Volunteer, Food Services, Other What is the Annual Target the organization seeks to reach? The 2013/2014 annual target for hand hygiene compliance in FH was 80% based on the provincial target strategy. FH achieved 79% compliance. Annual Report: Page 37

42 Benchmark Comparison: How does the rate compare to other areas? The provincial hand hygiene compliance is used as a benchmark for FH because of consistent methodology and reporting. The provincial fiscal annual compliance for fiscal year 2012/2013 was 73% which is the most recently published provincial annual rate. [Hand cleaning compliance in BC acute care facilities, fiscal year 2012/2013. Provincial Infection Control Network of BC (June 2013). Retrieved from 013%20Annual.pdf]. The 2013/14 annual hand hygiene compliance in FH was 79%; higher than the BC compliance of 73%. Trend: What does the data show? A total of 108,421 hand hygiene practice observations were completed in 2013/2014 for FH, accounting for a total compliance of 79% (see Table 4). Overall, FH hand hygiene compliance increased from 72% in 2012/2013 (103,424 observations). The acute care audits completed during fiscal year 2013/2014 (91,240 observations) provided an overall FH compliance rate of 79%, an increase from the 72% in fiscal year 2012/2013 (85,756 observations) (Figure 8). FH Sites The FH sites with the highest hand hygiene compliance and whom also achieved the FH target of 80% compliance for fiscal year 2013/2014 are: PAH (87%; 6083 observations), MSA (86%; 440 observations), CGH (84%; 3606 observations) BH (84%; 22,384 observations), DH (80%; 1735 observations) and SMH (80%; 16,646 observations) (Figure 8). Three sites that nearly reached the target with 79% compliance included ERH, JPOCSC and QPCC (Figure 9). The BH high number of observations reflects the site commitment to hand hygiene, conducting audits bi weekly rather than the FH policy requirement for once each fiscal period. High hand hygiene compliance for PAH and MSA also reflects the leadership and site commitment to hand hygiene best practices, communication, and improvement work. FH Programs The FH programs with the highest hand hygiene compliance were End of Life (89%; 2820 observations), Rehabilitation (85%; 2591 observations), Older Adult (85%; 4349 observations), and Home Health (83%; 1386 observations). Many programs were near, at or above the FH target of 80% hand hygiene compliance (Figure 10). See Appendix D for total number of observations by program. There is excellent support for hand Annual Report: Page 38

43 hygiene through program initiatives and improvement work as evidenced through these high program compliance rates. FH Health Care Provider Type The compliance by healthcare provider group in fiscal year 2013/2014for all FH staff was 81% for nursing (85,877 observations), 78% for clinical staff (12,059 observations), 63% for physicians (7,138 observations) and 63% for other staff (3,348 observations) (Figure 10). The majority of observations collected were in the nursing category which coincides with the fact that this group makes up the largest proportion of healthcare employees. Limitations: What may have affected the quality of this measure? Data collection methods and auditors 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 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. The total number of acute care observations has significantly increased in the past two fiscal years compared to prior years; therefore, caution must be used when comparing fiscal year results. Some sites, programs, and types of staff have a smaller total number of observations and may not be as representative of the overall population. Hand Hygiene Improvement Strategies The FH hand hygiene program continues to grow and expand across the organization with gradual improvements in hand hygiene compliance by all healthcare professionals, by sites and by programs. This is important as hand hygiene compliance is fundamental principle for all FH HAI reduction strategies. As part of an engagement strategy to facilitate awareness and improvement work, hand hygiene audits are conducted across all facilities throughout FH including all acute care units, FH operated residential facilities and many community programs and outpatient clinics. A key component of the audit and resultant improvement work is the public communication and reporting of hand compliance at many levels in across the organization The Form Audit hand hygiene system supports FH auditing and complex reporting capabilities and is readily available to all staff, always up to date and current Annual Report: Page 39

44 for anyone within FH who wishes to view or obtain a report. Unit level reports are posted on each facility acute care unit and updated each fiscal period or more frequently as audits are completed. Quarterly rates are posted at numerous locations throughout each facility. Performance metric reports for hand hygiene by site and by program are also distributed across the organization each fiscal period. Fiscal period hand hygiene reports are also available on the FH external website. A major contribution to the increase in rates was implementation of close to 40,000 new hand hygiene dispensers and products at point of care and at the entrance to each patient or treatment room across the continuum of care from acute care units to home health and community programs. New alcohol based hand rub, soap, lotion and antimicrobial color coded dispensers and associated products are provided by Deb Canada after a successful RFP awarded contract through Heath Shared Services of BC (HSSBC). Areas of focus for 2014/2015 will be continued enhancements to the hand hygiene audit and reporting program, including a pilot to explore the use of ipads to conduct audits at facilities and expansion of the current program to include more community and outpatient clinics, along with re certification program for auditors; engagement initiatives and improvements for staff, physicians, patients and visitors; assessment of new hand hygiene products and dispensers; follow up on the provincial hand hygiene survey and developing a communication and marketing hand hygiene strategy for FH. Comments The substantial work being conducted across FH with respect to hand hygiene improvement initiatives, including auditing for compliance, is in alignment with the work of the Provincial Hand Hygiene Working Group of British Columbia. Reprocessing of Medical Devices Reprocessing involves the complete cycle of transportation, pre cleaning, cleaning, disinfection or sterilization, storage, and use of reusable AND disposable medical devices and patient care equipment following best practices standards. FH continues to follow the British Columbia MoH s Best Practice Guidelines for the Cleaning, Disinfection and Sterilization of Medical Devices in Health Authorities (November, 2011) for a comprehensive overview of reprocessing activities for medical devices and patient care equipment. The BC MoH mandates that health authorities increase patient safety by ensuring compliance with established standards for reprocessing of medical Annual Report: Page 40

45 devices and patient care equipment (e.g., Public Health Canada and the Canadian Standards Association). FH completed audits and implemented a series of regional reprocessing polices and remediation activities, including Standard Operating Procedures (SOPs) and education material to guide the reprocessing of patient care equipment and medical devices. The organization will continue to monitor reprocessing practices through cyclical audits of programs and reporting of gaps through program quality committees that report to the FH QPC. Status Improvement Increase in Compliance (high-risk areas) Target 95% Actual (2013/2014) 96% Increase in Compliance (low-risk areas) 85% 98% new audit tool implemented in 2012/2013 ^ includes JPOSC * includes residential care sites except in 2010/2011 Audit. Figure 12: Reprocessing compliance by sector and fiscal year for FH overall Annual Report: Page 41

46 includes JPOCSC (see Appendix E for compliance results for high risk areas) Figure 13: Reprocessing compliance in high risk areas, SPD & OR, 2012/2013 & 2013/2014 (SeeAppendix F: for compliance results for low risk areas, FH community sector) Figure 14: Reprocessing compliance for low risk areas, FH community sector, 2013/2014 Annual Report: Page 42

47 What is being measured? A standardized provincial audit tool that evaluates compliance with the Canadian Standards Association (CSA) standards and BC MoH 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 is used. All FH areas, units, programs, and sites that are responsible for any of the steps of reprocessing, including transportation, pre cleaning, cleaning, disinfection or sterilization, storage, and/or use of medical devices, are audited according to the risk classification (of the steps undertaken within that program). Compliance evaluation also includes purchasing and education/orientation for reprocessing. High risk areas (e.g., those that pre clean, clean, high level disinfect, or sterilize) are audited annually. Low risk areas (e.g., those that transport, store, and use items) are audited on a threeyear cycle. Methodology A computerized program is used to conduct the audit assessments. This program 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 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 auditors submit the data to an internal FH database, and the IPC epidemiologist collates and provides reports. Audits were conducted by subject matter experts of the FH reprocessing team: an IPC Reprocessing Consultant and a Reprocessing Data Analyst, experts from the Sterile Processing Department (SPD), as well as Community, Residential care and Assisted Living, Mental Health and Substance Use Services consultant experts. The audits were conducted in association with the program managers, CNEs or CRNs, and front line staff responsible for the reprocessing activities for that program. What is the Annual Target the organization seeks to reach? The target compliance in 2013/2014 remains unchanged from 2012/2013, 95% compliance for high risk areas and 85% compliance for low risk areas as intermediate goals to achieve 100% compliance as defined by the BC MoH. Annual Report: Page 43

48 Benchmark Comparison: 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 comparable rates are publicly available. FH has been recognized by the BC MoH as auditing units and programs more broadly than other Health Authorities, making it impossible to compare results and set comparable benchmarks. Trend: What does the data show? A new audit tool was implemented for FH in fiscal year 2012/2013, so comparisons within FH can only be undertaken from this year and the last with additional comparisons to previous years inappropriate, as the audit questions are dissimilar and the questions have been expanded upon. This year, due to the delay in filling vacancies within the Reprocessing team, only the SPD units were audited among acute care sites. The compliance ranged from a high of 99% at CGH to a low of 89% at MMH. All SPDs met or exceeded last year s compliance results. The greatest improvement is seen in the jump in compliance from 79 to 97% in RCH high risk areas. Low risk areas are on a 3 year cycle meaning each year, approximately 1/3 of sites are audited. Therefore, comparison to last year s audit is anomalous as each year is auditing a different group. Among this year s cross section of low risk areas in community sites, included residential care and MHSU (including Residential Care Health Service Providers (HSP) and Owned and Operated sites), Public Health Units, and Home Health. HSPcontracted sites achieved an astounding 100% compliance up from 99% last year with Public Health Units having the lowest compliance at 95% (but with a staggering increase of 25% in compliance). Limitations: What may have affected the quality of this measure? The audits are somewhat subjective based the auditor s interpretation of the audit question and interpretation of the standards, as well as the knowledge level 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, and year three pre emptively identified high risk equipment and requested information about the reprocessing of these items. As the next year of reprocessing is being initiated, reprocessing of specific equipment is being evaluated and work is being completed to standardize reprocessing steps to meet industry Annual Report: Page 44

49 standards. Additionally, FH is committed to expanding the audit to include a greater range of sites, units, or programs. This year, the audits were expanded to community MHSU sites. Next fiscal year, FH is adding Facilities Management and Operations as well as Procurement, Stores, and Warehousing. Comments There is a provincial initiative for standardized education that has globally impacted the FH that are not in scope for remediation by individual programs. Additionally, there are FH wide initiatives underway, considered regional in scope, that are being remediated by the FH reprocessing team, not by the individual programs or sites. Examples include development of an FH wide policy for purchasing and dissemination of the education requirements created for the SOPs. For the questions impacted by provincial and regional improvement work, FH auditors applied standardized answers to some of the questions as outside the responsibility of the unit/program. Without the development and dissemination of the policy and clinical practice guidelines, units and programs cannot be held accountable for meeting a question that has not yet been delineated and disseminated at a regional level. These regional initiatives score a no response or non compliance on the audit, which impacts the overall compliance rate, but as these regional initiatives are resolved, the expectation is there will be a general improvement in compliance scores across the continuum of care. In addition to the Reprocessing audit, additional support has been provided by IPC program to support Reprocessing as a whole by supporting units and programs to creatework instructions for equipment used on units affected by CPE cases. These work instructions have been expanded to non critical medical devices (which fall outside the scope of the BCMoH audit). The IPC program also provides support to units to complete work instructions for all medical devices within FH using an approved template that incorporates the MSDSs and the MIFUs. This is an extensive amount and work that will continue to be a focus for 2014/2015. Another component of work for the IPC consultants who participate in the reprocessing audits and remediation work is to participate in all provincial Reprocessing Working Group document development, reviews and revisions. Areas of focus for 2014/2015 will be on going fiscal year audits in alignment the FH Reprocessing audit schedule. The IPC program plans to implement of a new automated web based reprocessing audit tool platform that will facilitate standardized processes for remediation entry and regular reports with the FH clinical programs that are audited. Annual Report: Page 45

50 Outbreak Management Gastrointestinal Illness Outbreaks Figure 15: Comparison of Gastrointestinal Illness outbreaks in acute care sites by type of outbreak and fiscal year Annual Report: Page 46

51 Figure 16: Gastrointestinal illness outbreaks in acute care facilities by type of outbreak and month, 2012/2013 & 2013/2014 Figure 17: Gastrointestinal illness outbreaks in acute care facilities by FH city, 2012/2013 & 2013/2014 Annual Report: Page 47

52 Table 5: Etiological agents identified from declared Gastrointestinal Illness outbreaks in FH acute care by fiscal year Fiscal Year Norovirus CDI Noro/CDI Other GI/ Unknown No test 2011/ / / What is being measured? The total number of gastrointestinal illness (GI) outbreaks and their impact on acute care sites in FH, including the pathogen responsible, total number of outbreaks declared, and the month and city associated with outbreak declaration. Methodology Total Surveillance and oversight of acute care outbreaks is carried out by IPC Practitioners who are notified by front line staff of symptoms consistent with gastroenteritis, which include otherwise unexplained vomiting and/or diarrhea. IPC Practitioners use standardized case definitions to determine if a GI outbreak should be declared. Acute care outbreaks are reported through standardized outbreak notification s, which include FH wide posting of all outbreaks that are in progress. IPC Practitioners monitor and record all acute care outbreaks in an FH internal database. C.difficile Infection Outbreak Reporting The IPC program began declaring and reporting C.difficile Infection (CDI) outbreaks in acute care sites in In FH, a CDI outbreak is defined as three or more new healthcare associated cases of CDI attributed to a unit (as defined by geographical area, nursing station, and unit mnemonic) in a seven day period. A province wide, standard outbreak definition is under development. In fiscal year 2013/2014 there were no mixed Norovirus/CDI outbreaks reported compared to 6 mixed outbreaks reported in fiscal year 2012/2013 and 15 mixed outbreaks reported in 2011/2012. Improvements to testing and communication processes enabled explicit declaration of outbreaks as either Norovirus or CDI in fiscal year 2013/2014 (Figure 15and Table 5). Annual Report: Page 48

53 Trend: What does the data show? In fiscal year 2013/2014 (Apr 1/2013 Mar 31/2014), there were a total of28gi outbreaks (all pathogens) declared in FH acute care sites, compared to 39 in fiscal 2012/2013 and 34 in fiscal year 2011/2012 (see Figure 15and Table 5). It appears there has been an increase in the number of norovirus outbreaks over the past 3 fiscal years (from 4 to 17), but this is probably because outbreaks previously referred to as mixed are now being correctly classified as norovirus or CDI. CDI outbreaks have decreased over this fiscal year with 11 CDI outbreaks in 2011/2012, 14 CDI outbreaks in 2012/2013 and only 9 CDI outbreaks in 2013/2014. The majority of GI outbreaks (all pathogens) occurred during the typical outbreak season between November and March with sporadic activity in other months (Figure 16). The regional distribution of GI outbreaks in FH for fiscal years 2012/2013 and 2013/2014 indicates higher activity in the major city centres of Langley, New Westminster, and Surrey (see Figure 17). This effect may be the result of the population density and number of facilities in these regions. In fiscal year 2013/2014 there were a total of 28GI outbreaks declared in FH acute care sites; 17 outbreaks were attributed to Norovirus, 9 outbreaks were attributed to CDI and 2 outbreaks were unknown. Comparison to previous fiscal years is available in Table 5. Limitations Norovirus and CDI outbreaks often coincide, as increased norovirus activity means that fecal material colonized with C.difficile spores is more prevalent and more likely to contaminate the environment and cause transmission. Diarrheal symptoms due to norovirus may prompt testing for C.difficile, and mislabelling of patients who are only colonized with C.difficile. Outbreak Management Improvements As part of the FH initiative to decrease CDI incidence rates across the organization, a rigorous GI policy with clinical practice guidelines for management of GI cases and outbreaks was developed. These GI protocols mandate the escalation of IPC initiatives depending on the number and prevalence of cases on a unit and the deployment of a rapid response Outbreak Management Team (OMT) if an outbreak (either Norovirus or CDI)is declared. Annual Report: Page 49

54 The hands on approach of the OMT is crucial to the timely cessation of the outbreak. The approach consists of daily teleconferences with leadership and key stakeholders from the facility and affected unit. The IPC practitioner keeps a detailed line list with new cases added as they occur for discussion and consultation with the IPC Executive Medical Director. IPC best practices are reviewed and assessed, including closure of patient kitchens, decluttering activities, emphasis on hand washing and increased frequency of audits, IPC education on principles and best practices, cleaning of shared patient equipment, dedicated toileting facilities, closure of hallway beds and review of environmental cleaning practices. Daily communication s and alerts are distributed to affected stakeholders including updated outbreak data and IPC best practice reminders. Outbreaks are also posted on the FH public website. This multipronged strategy minimizes the impact and duration of the outbreaks across FH. Areas of focus for 2014/2015 continue to be prevention of outbreaks through fall education sessions; management of outbreaks including standardization of outbreak processes and protocols; emphasis on hand hygiene compliance for staff, physicians, patients and visitors; dedicated toileting facilities; cohorting of patients and staff; appropriate cleaning of medical devices. Outbreak Lessons Learned 2013/2014 On site practitioner support seven days a week while an outbreak is ongoing Use of a line list as a communication and analysis tool for the IPC program Declaring ʺalertsʺ and putting control measures in place as a way of preventing outbreaks, including closing all hallway/overflow and other beds without toilets and hand hygiene facilities during the alert phase prior to declaring an outbreak Specific attention paid to addressing the risk factor of ʺwandering patientsʺ for starting and maintaining outbreaks The importance of frequent sporicidal disinfection of all washrooms during GI outbreaks Pulling together an outbreak team (that includes IPC, site leadership, the unit leaders, housekeeping and access) when an outbreak is declared, with daily teleconferences to identify and mitigate site based risk until the outbreak is over Ensuring that there is physician and IPC oversight seven days a week while an outbreak is ongoing Annual Report: Page 50

55 Enhanced Emergency Department cleaning for all acute care sites from December 01 through March 31. Annual Report: Page 51

56 Appendix A: Structure and Accountability for IPC Program Annual Report: Page 52