Infection Prevention and Control. A focus on patient safety

Transcription

1 Infection Prevention and Control A focus on patient safety Annual Report for

2 Table of Contents Executive Summary... 4 Introduction... 7 Healthcare Associated Infection (HAI) Indicators Clostridium difficile Infection (CDI) Methicillin-Resistant Staphylococcus aureus (MRSA) Best Practice Hand Hygiene Compliance Reprocessing of Medical Devices Outbreak Management IPC Program FH Strategic Initiatives Education Competencies, Certifications, and Membership IPC Program FH Strategic Initiatives Summary of Initiatives Appendices Appendix A: Dr. Michael Gardam Report Recommendations and Completed Actions Appendix B: Structure and Accountability for IPC Program Appendix C: IPC Program Organization Chart Appendix D: FH Acute care beds Appendix E: Fiscal Period IPC Metrics Report for 2012/ Appendix F: Hand Hygiene Compliance Appendix G: Reprocessing Compliance Appendix H: Terminology and Abbreviations Page 2

3 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 facility-associated CDI incidence rate by FH site, 2012/ Figure 3. Number of new CDI and healthcare-associated CDI incidence rate by FH program, 2012/ 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, 2012/ Figure 6. Number of new MRSA and facility-associated MRSA incidence rate by FH program, 2012/ Figure 7. Comparison of hand hygiene compliance by fiscal year in FH acute care sites Figure 8. Hand hygiene compliance among all staff by FH site, 2012/ Figure 9. Hand hygiene compliance among all staff by FH program, 2012/ Figure 10. Hand hygiene compliance by health care provider group for FH overall, 2012/ Figure 11. Reprocessing compliance by year for FH Figure 12. Reprocessing compliance in high-risk areas (SPD & OR), 2012/ Figure 13. Reprocessing compliance for low-risk areas, FH community sector, 2012/ Figure 14. Comparison of Gastrointestinal illness outbreaks in acute and residential care facilities by type of outbreak, fiscal years 2011/12 & 2012/ Figure 15. Gastrointestinal illness outbreaks in acute and residential care facilities by month, 2012/ Figure 16. Gastrointestinal illness outbreaks in acute and residential care facilities by FH city, 2012/ Figure 17. Comparison of respiratory illness outbreaks in acute and residential care facilities by type of outbreak, fiscal years 2011/12 & 2012/ Figure 18. Respiratory illness outbreaks in acute and residential care facilities by month, 2012/ Figure 19. Respiratory illness outbreaks in acute and residential care facilities by FH city, 2012/ TABLES Table 1. Hand Hygiene Compliance by Type of Fraser Health facility, fiscal year 2012/ Table 2. Etiological Agents Identified from Declared Gastrointestinal Illness Outbreaks in FH, Fiscal Year 2012/ Table 3. Etiological Agents Identified from Declared Respiratory Illness Outbreaks in FH, Fiscal Year 2012/ Table 4. IPC Program Strategic Initiatives Page 3

4 Executive Summary INFECTION PREVENTION AND CONTROL A focus on patient safety 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 in healthcareassociated infections Indicator Name CDI MRSA Hand Hygiene Compliance Reprocessing Compliance Outbreak Management Status Improvement Target Actual N/A Reduction in Rate Reduction in Rate Increase in compliance Increase in compliance Increase in compliance Reduction in # of Outbreaks 6.0 per 10,000 patient days 5.9 per 10,000 patient days 7.2 per 10,000 patient days 5.7 per 10,000 patient days Page # 80% compliance 73% compliance 22 95% compliance (high-risk areas) 85% compliance (low-risk areas) N/A % compliance 29 93% compliance 29 Increased level of GI and Respiratory outbreak activity Infection Prevention and Control (IPC) at Fraser Health (FH) is very pleased to present the 2012/2013 annual report. IPC is a core support 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 Patient 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, IPC in FH welcomes your feedback on this report. A large part of the success for decreasing Clostridium difficile infection incidence (CDI) rates this fiscal year can be attributed to the implementation of Dr. Michael Gardam s Clostridium difficile infection review recommendations (see Appendix A for Dr. Gardam s report from February 2012, including recommendations and actions completed). Implementation of the recommendations from Dr. Gardam s report, along with focused, committed work from the organization and from the IPC program and practitioners led to a 36% decrease in the overall FH CDI incidence rate and a 13% increase in overall FH hand hygiene compliance. Key recommendations and high level actions from the Michael Gardam report include: Development of a new IPC accountability structure in which IPC Practitioners have operational reporting responsibility to Site Directors and the IPC program is responsible for IPC Practitioner professional practice (see Appendix B for flow chart). Development of a new IPC program model that includes: (a) an IPC quality consultant role that will support the culture and behavior change for programs regarding adoption of strong infection prevention and control best practices and protocols; and (b) a medical model to support infection prevention and control standards and best practices. The medical model is led by an Executive Medical Director who chairs the Regional Department of Infection Prevention and Public Health with membership from acute care sites Heads of Department (local). 35 Page 4

5 Expansion of resources for the IPC program addition of 15.5 FTE (a combination of Practitioner and Consultant roles) along with an additional manager position. Creation of local IPC committees at each site chaired by the Head of Department (local) and the Site Director with accountability for infection prevention and control at the facility. Development of a new Gastrointestinal Illness (GI) policy, clinical practice guidelines, CDI case review protocols, and improvement plans for IPC Practitioners use and dissemination at the site and unit levels and the IPC Consultants through a regional and program lens. Conducted full facility enhanced cleans at six FH acute care sites that had the highest rate of CDI in 2011/12 and 2012/13. In collaboration with Business Initiatives and Support Services (BISS) and FH P3 partners, implementation of an escalation process for enhanced cleaning protocols for all GI cases across acute care sites. This includes cleaning of every room with a GI case on each unit, alert level cleaning for the entire unit when the unit reaches a level meeting the definition of high bio burden (> than 10% of rooms on the unit have a patient with CDI), an outbreak clean (similar to an alert level clean) in which the unit is closed for admission and transfers); and a special Emergency Department (ED) enhanced clean during the influenza season, which was also initiated during times when increased GI cases were presenting in the EDs. FH discontinued Vancomycin Resistant Enterococcus (VRE) screening and isolation requirements for colonized cases at FH facilities and developed a specific surveillance plan to track VRE infections and negative outcomes to monitor any impact of these changes to patient safety. Additional initiatives that contributed to the success for the program this fiscal year include: CDI improvement work such as de-cluttering the facility/environment, at the unit and patient room level; ensuring all medical devices and patient care equipment were cleaned and disinfected appropriately (i.e., the right product at the right time); hand hygiene compliance improvement initiative; cohorting of GI patients appropriately; chart reviews of CDI cases; and review of antimicrobials by pharmacy. The IPC program collaborated with other providers including Health & Business Analytics and external vendors to advance reporting of IPC indicators including CDI, MRSA, and hand hygiene compliance in an effort to increase transparency, provide data in an electronic format that was timelier, detailed, readily accessible in user-friendly tools, and provided information for dissemination to an FH-wide audience. The IPC program worked in partnership with an external vendor (Crede Technologies), on the development and implementation of a robust hand hygiene audit and reporting system (FormAudit) that supports the hand hygiene auditor, improves reporting hand hygiene compliance across the continuum of care, and can be broken down by type of health care provider (program or group specific categories). Based on this year s report, the key priorities for next year will be: Ongoing support, improvement initiatives, and sustainment for Healthcare Associated Infection reduction, particularly CDI Review and update the FH IPC manuals, policies, and procedures Enhancements to surveillance system and addition of protocols to include emerging Antibiotic Resistant Organisms Stakeholder integration of IPC standards and best practices including construction projects and procurement processes Page 5

6 Reprocessing remediation initiatives and audits including QA framework action plan Improvement initiatives for hand hygiene compliance, including implementation of new hand hygiene products Leadership and promotion for Antimicrobial Stewardship initiatives Page 6

7 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 2012/13, the IPC program continued to expand; filling practitioner vacancies at FH sites, hiring quality improvement consultants into this newly developed role and appointment of Dr. Elizabeth Brodkin as IPC program Medical Director. 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 (see Appendix B for flow chart). The IPC 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, and national quality and patient safety organizations and related initiatives, such as the Provincial Infection Control Network (PICNet), Safer Healthcare Now!, the Canadian Patient Safety Institute, the Institute for Healthcare Improvement, and Accreditation Canada. Infection prevention and control across the organization is accomplished by: Surveillance, trending, and reporting of site and program-based healthcare-associated infections to increase awareness and response 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, third party providers, patients, clients, residents, and visitors Strategic initiatives and improvement actions for fiscal year 2012/2013 consisted of the following categories: Processes that support the Dr. Michael Gardam recommendations Reprocessing audits and remediation work Environmental service support Hand hygiene audits, comprehensive and timely reports, and improvement initiatives IPC standards and best practices Hospital acquired Infections (HAIs) surveillance and methodology IPC human resources and IPC model accountability IPC professional development Construction IPC standardization of purchasing and procurement 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, Quality and Patient Safety, Integrated Risk Management, Human Factors, Workplace Health, and numerous other programs across the Health Authority (see Appendix C for an organizational chart). The IPC Annual Report is organized in three sections: Executive Summary and Introduction Healthcare Associated Infection (HAI) Indicators Surveillance Best Practice Knowledge Transfer: IPC Program FH Strategic Initiatives Education Page 7

8 Infection Prevention and Control Leadership Dr. Andrew Webb Vice-President, Medicine Dr. Elizabeth Brodkin Executive Medical Director Petra Welsh Director, IPC Strategy and Performance Sandra Daniels/ Valerie Schall / Rene Pitts IPC Managers Tara Leigh Donovan Epidemiologist Sergio Pastrana Health Data Analyst Lindsay MacDonald Strategic Transformation Lead Karen Mok Hand Hygiene Coordinator Karen Hofmann Administrative Assistant Infection Prevention and Control Practitioners and Consultants (alphabetical order by surname)* * This list depicts all staff that was part of the program during the 2012/13 reporting period. IPC Practitioners Abed, Vlada Baddan, Sandeep Bleackley, Pat Bos, Stephanie Butler-Lim, Susan Dickson, Terry Dorais, Sebastien Emley, Kirsten Gara, Aleks Giesbrecht, Amanda Imamovic-Bul, Amira Page 8

9 Johal, Rani Johnson, Janie Kim, Lauren McLean, Rhonda Mendes, Adriana Paige, Michelle Rogers, Karen Sohi, Raj Tjosvold, Sandra Verbeck, Jan Wong, Winnie IPC Consultants Brierton-Joseph, Iona Chisholm, Paul Esmail, Noorsallah Espezel, Hilary Hlagi, Jacquie Ibrahimov, Fuad O Donnell, Catherine Ormond, Sarah Parent, Sharon Reimer, Lisa Taha, Fatma Page 9

10 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 and Pathologists, Medical Program Directors, Physicians, Executive Directors, Site Directors, 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 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 Health & Business Analytics Environmental Services Facilities Maintenance & Operations Health Promotion and Prevention Health Shared Services BC Information Management Integrated Risk Management 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 Page 10

11 Healthcare Associated Infection (HAI) Indicators Clostridium difficile Infection (CDI) Clostridium difficile infection (CDI) is one of the most commonly acquired healthcare-associated 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) Number of new healthcare-associated CDI attributed to the same FH acute care site where CDI was most likely acquired and confirmed or diagnosed (does not account for cases that are transferred between sites where CDI was acquired vs. where CDI was confirmed or diagnosed) / total patient days for particular site or FH total * 10,000 Healthcare-associated CDI incidence rate (for programs) Number of new healthcare-associated CDI attributed to the FH acute care site where CDI was most likely acquired / total patient days for particular program * 10,000 Status 1 Improvement Reduction in rate Target 6.0 per 10,000 patient days Actual (2012/13) 7.2 per 10,000 patient days Figure 1. Number of new CDI and facility-associated CDI incidence rate per 10,000 patient days by fiscal year for FH 1 = 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; = problem area: actual is not meeting target and not meeting Canadian benchmarks. Page 11

12 Figure 2. Number of new CDI and facility-associated CDI incidence rate by FH site, 2012/13 Figure 3. Number of new CDI and healthcare-associated CDI incidence rate by FH program, 2012/13 Page 12

13 Methodology: CDI case identification and confirmation is completed by the IPC Practitioners using a standardized case definition and protocol to identify cases from medical microbiology reports, admission reports, and chart reviews. 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. The case definition of CDI is met when any of the following criteria apply among admitted inpatients: 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 b. diagnosis of toxic megacolon OR 2. Diagnosis of pseudomembranous colitis on sigmoidoscopy, colonoscopy, or histological/pathological diagnosis of CDI 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 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 end of previous symptoms 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 cases of CDI among admitted acute care inpatients. Exclusion criteria: outpatients, residential care patients/residents, children less than one year of age, and relapses. Relapses are defined as a confirmed case of CDI with recurrence of diarrhea within two to eight weeks from the previous specimen collection date or the date of diagnosis of the previous episode, provided prior CDI-related diarrhea resolved with or without treatment. A relapse is attributed to the source of the original infection (e.g., healthcare associated or community). What is the Annual Target the organization seeks to reach? The FH target for 2012/2013 fiscal year was 6.0 per 10,000 patient days, based on the 2011 Canadian Nosocomial Infection Surveillance Program (CNISP) overall facility-associated CDI rate that includes national data from 35 hospitals (adult and mixed sites) [Presentation at CNISP Annual Meeting, January 19, 2012]. The FH CDI incidence rate for 2012/13 (7.2 per 10,000 patient days) was above the target. Benchmark & Comparators The FH CDI incidence rate for 2012/13 (7.2 per 10,000 patient days) was above the provincial 2011/12 benchmark of 8.1 per 10,000 patient days, based on the provincial CDI rate provided by PICNet [Provincial Infection Control Network of BC (2012)]. Clostridium difficile infection (CDI) surveillance report for fiscal year 2011/12. Retrieved from Each site and program uses their previous fiscal year annual incidence rate as a benchmark for CDI improvement. Page 13

14 Trend: What does the data show? Overall FH For the past eight fiscal years, the FH CDI incidence rate has fluctuated. The 2012/13 FH CDI incidence rate of 7.2 per 10,000 patient days (95% CI = ) is noteworthy, as it represents a statistically significant decrease from the previous fiscal year rate of 11.3 per 10,000 patient days in 2011/12 (95% CI = ) (see Figure 1). The CDI incidence rate decreased 36% from 2011/12 to 2012/13. FH Acute Care Sites In 2012/13, the CDI incidence rate was highest among LMH, RCH, BH and ERH (see Figure 2). The CDI incidence rates among FH sites ranged from zero at FCH to 11.6 per 10,000 patient days (90 new CDI) at LMH (see Figure 2). FCH is a community hospital and is the smallest FH site, with the majority of units dedicated to residential care patients with the exception of one unit for medicine patients (10 funded acute care beds). The small size and specific patient population of this site may explain the rationale for this site having no new CDI in 2012/13. Possible rationale for the high CDI rate at LMH may be the result of the facility having an older infrastructure, with a number of physical issues and congestion challenges that make application of infection prevention and control best practices more complicated. SMH (167 new CDI) and RCH (160 new CDI) accounted for the greatest number of new CDI among FH acute care sites (see Figure 2). SMH and RCH are tertiary/referral hospitals and are the largest acute care sites, often dealing with surge capacity issues and caring for patients experiencing comorbidities and health complications including critical illnesses. FH Acute Care Programs In 2012/13, the incidence rate was highest among the Older Adult and Medicine programs (see Figure 3); 17.1 per 10,000 patient days (81 new CDI) and 12.2 per 10,000 patient days (419 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. Medicine and Surgery (106 new CDI) accounted for the greatest number of new CDI among FH acute care programs (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 one or two cases leads to a high facility rate (see Appendix D for FH acute care bed numbers for fiscal year end 2012/13). Additionally, Clostridium difficile testing practices, case management, and case definition application have varied over the years or across sites and programs, which will affect the rates. The IPC program continues to encourage standardization and accurate and effective application of infection prevention and control practices and definitions across FH. IMPORTANT: FH laboratories introduced new PCR testing methods for CDI stool samples. 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, Comments: 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, inaccurate and/or infrequent environmental cleaning practices, inappropriate or delayed application of additional precautions, low availability of sinks in patient rooms, and inaccurate use or low availability Page 14

15 of closed human waste disposal systems. 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. What actions have been taken over the last year? Developed a Gastrointestinal Illness (GI) policy, clinical practice guidelines, and supporting tools for use by all FH staff and physicians. New changes include: (a) strict cohorting protocols, (b) immediate use of Contact Precautions Plus for all GI cases, (c) an escalated series of enhanced cleaning protocols, (d) standardization of the CDI definition, and (e) clarification of outbreak management actions and responsibilities Conducted extensive improvement initiatives that included: (a) full facility enhanced cleans with sporicidal agents twice per day; (b) an escalated series of enhanced cleans for individual GI cases up to outbreak level cleaning, including special Emergency Department cleaning throughout the flu season; (c) extensive work in de-cluttering the facilities, units, and patient rooms; (d) developed guidelines to ensure all medical devices and patient care equipment are being cleaned appropriately (i.e., the right product at the right time); (e) hand hygiene compliance improvement; (f) appropriate cohorting of GI patients; and (g) review of antimicrobials by pharmacy Collaborated with Health & Business Analytics to launch a CDI/MRSA Surveillance Reporting Tool, available on the FHPulse, allowing for more timely dissemination of rates and number of cases by site, program, and unit to facilitate improvement work for various phases of action Worked in partnership with Health & Business Analytics to design a single-source, electronic CDI surveillance system with automated lab reporting and amalgamated patient record details to facilitate CDI case reviews Developed a CDI case review tool in order to assess the risks and management associated with healthcareassociated CDI Implemented CDI outbreak line lists with pertinent patient details to inform responsible staff and decisionmakers in order to better manage CDI outbreaks Continued weekly reporting of CDI cases by IPC Practitioners Initiated an improvement collaborative for FH programs and fostered the growth of CDI prevention imperatives into front-line culture and everyday practice Continued implementation of additional closed waste disposal systems that will decrease contamination of environment and exposure risk to patients and staff Participation and reporting of CDI incidence rates and number of cases to PICNet, FH QPMS, and the BC Ministry of Health (MoH) Implemented Dr. Michael Gardam s recommendations in an effort to reduce CDI across FH as discussed in the Executive Summary; highlights include: Changed organizational emphasis to include the use of alcohol-based hand rub in addition to soap and water for CDI Implemented an enhanced medical model structure with resources to support the IPC decisions and initiatives at sites and regionally across FH; this began with appointing an Executive Medical Director for IPC, Dr. Elizabeth Brodkin Improved antimicrobial stewardship: developed pre-printed CDI orders, implemented automatic stop orders for antimicrobials, and initiated CDI order sheets for patient charts Page 15

16 Expanded IPC service delivery through the hiring of additional IPC Practitioners at sites and Consultants to support regional program initiatives and IPC functional areas of work (such as reprocessing, purchasing and construction); this includes regional coverage of evening and weekend hours as well as additional coverage during outbreaks Implemented an escalated series of enhanced sporicidal cleaning protocols by contracted housekeeping services; Developed standardized site-based local infection prevention and control committees (IPCCs) that report through the FH IPCC to the Board Revised the Vancomycin Resistant Enterococcus (VRE) policy and surveillance protocols to ensure resources and effort dedicated to areas of need Clarification of housekeeping contracts to include additional cleaning protocols, review of external audits and review requirement for additional internal FH housekeeping audits Publically posted unit and facility hand hygiene compliance and CDI and MRSA rates (see Appendix E for 2012/2103 IPC metrics report) Ensured accountability for infection prevention and control at the facility level where IPC Practitioners report to Site Directors for day-to-day operations with professional accountability to the IPC program Focused work and education on the units by IPC Practitioners with unit managers, PCCs, and front-line staff through use of IPC best practice audits and de-cluttering initiatives Completed a draft of FH Housekeeping Standards for incorporation into FH Infection Prevention and Control Manual What improvement actions are planned for the next fiscal year? Work with BISS and housekeeping contracted services to ensure unit-level service agreements are in alignment with the new FH housekeeping manual, develop a library of chemicals for use by housekeeping services, and explore alternative audit and room cleaning processes Continue with hand hygiene compliance improvement initiatives (see hand hygiene section) Develop education modalities and material for GI policy and clinical practice guidelines, engagement of the organization in the education and GI improvement work(this includes BISS and contracted housekeeping service staff), and then evaluate the effectiveness of the policy and sustainment of this improvement work Develop flu-school education material and conduct the sessions prior to GI season Continue to provide subject matter IPC and quality improvement expertise to plan, develop, and implement improvement actions for units that are most vulnerable for transmission of CDI (based on FH surveillance data) in collaboration with facilities and clinical programs Continue to work and develop the FH Infection Prevention and Control Manual, based on the completed IPC decision and position documents and prioritized areas of focus Evaluate automatic stop orders in conjunction with the FH antimicrobial stewardship team Complete CDI case reviews on all new healthcare-associated CDI, escalating the cases through the PSLS for those with unexpected and/or poor outcomes Implement and evaluate the new electronic CDI surveillance system Physical, public posting of CDI rates at FH sites and electronic access to rates on the FH external website Automate and electronically generate weekly CDI reports for IPCPs to disseminate to sites Page 16

17 Develop a protocol and conduct a pilot of Fecal Transplantation an emerging therapy for patients with relapsing CDI Develop a general IPC refresher education policy and program for IPC best practices for all staff and physicians Continue work with physicians and the Antimicrobial Stewardship Committee on antimicrobial stewardship and prescribing initiatives 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 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) Number of new healthcare-associated MRSA attributed to the same FH acute care site where MRSA was most likely acquired and confirmed or diagnosed (does not account for cases that are transferred between sites where MRSA was acquired vs. where MRSA was confirmed or diagnosed) / total patient days for particular site or FH total * 10,000 Healthcare-associated MRSA incidence rate (for programs) Number of new healthcare-associated MRSA attributed to the FH acute care site where MRSA was most likely acquired / total patient days for particular program * 10,000 Status 2 Improvement Reduction in rate Target 5.9 per 10,000 patient days Actual (2012/13) 5.7 per 10,000 patient days 2 = 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; = problem area: actual is not meeting target and not meeting Canadian benchmarks. Page 17

18 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, 2012/13 Page 18

19 Figure 6. Number of new MRSA and facility-associated MRSA incidence rate by FH program, 2012/13 Methodology: MRSA (colonization or infection) case identification and confirmation is completed by the IPC Practitioners using a standardized case definition to identify cases from various sources, including medical microbiology reports, admission reports, and chart reviews. IPC Practitioners enter all cases into an internal FH database. The IPC health 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 to a healthcare-facility within the last 12 months. Inclusion criteria: all newly confirmed cases of MRSA infections or colonizations among admitted acute care inpatients. Exclusion criteria: outpatients, residential care patients/residents. Page 19

20 What is the Annual Target the organization seeks to reach? The FH MRSA incidence target rate is 5.9 per 10,000 patient days, based on the 2010 Canadian Nosocomial Infection Surveillance Program (CNISP) overall facility-associated MRSA rate (infections + colonizations), which includes national data from 35 hospitals (adult and mixed sites) [L. Forrester, personal communication, September 25, 2012]. The FH MRSA incidence rate for 2011/12 was slightly below the target at 5.7 per 10,000 patient days. FH has remained below the national benchmark for the past four fiscal years. Benchmark & Comparators: How does the rate compare to other areas? The overall FH benchmark is the Provincial MRSA incidence rate of 4.2 per 10,000 patient days for fiscal year 2011/12 (Provincial Infection Control Network of BC, 2012). Methicillin-resistant Staphylococcus aureus (MRSA) surveillance report, Fiscal year 2011/12. Retrieved from The FH 2012/13 MRSA incidence rate of 5.7 per 10,000 patient days was above the provincial benchmark. Each site and program uses their previous fiscal year annual incidence rate as a benchmark for MRSA improvement. Trend: What does the data show? The annual incidence of MRSA in FH acute care sites declined over four consecutive fiscal years from a high of 7.8 per 10,000 patient days in 2007/08 to a low of 4.7 per 10,000 patient days (95% CI = ) in 2010/11 and 2011/12 (see Figure 4). The rate has since increased in 2012/13 to 5.7 per 10,000 patient days (95% CI = ), representing a statistically significant change from the prior two most recent fiscal years. The MRSA incidence rate increased 21% from 2011/12 to 2012/13. FH Acute Care Sites In 2012/13, the MRSA incidence rate was highest among RMH, FCH, and SMH (see Figure 5). The MRSA incidence rates among FH sites ranged from a low of 2.0 per 10,000 patient days (16 new MRSA) at LMH to a high of 10.2 per 10,000 patient days (62 new MRSA) at RMH. SMH (171 new MRSA) and RCH (124 new MRSA) accounted for the greatest number of new MRSA cases among FH acute care sites (see Figure 5). FH Acute Care Programs In 2012/13, the MRSA incidence rate was highest among the Older Adult and Medicine programs (see Figure 6); 12.0 per 10,000 patient days and 10.4 per 10,000 patient days respectively. These two clinical programs care for the elderly and/or patients with comorbidities who may require antibiotics during their hospitalization. Antibiotic exposure is a known risk factor for acquisition of MRSA, which may explain the higher rates among these programs. Medicine (358 new MRSA) and Surgery (125 new MRSA) accounted for the greatest number of new MRSA among FH programs (see Figure 6). Limitations: What may have affected the quality of this measure? 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 across 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. Page 20

21 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 is not possible. 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, un-available 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. What actions have been taken over the last year? Participated in provincial surveillance and reporting for MRSA to PICNet BC and the BC Ministry of Health (MoH) Developed and implemented an FH policy for automatic stop orders of antimicrobials provided by the FH Antimicrobial Stewardship Committee to focus on the reduction of inappropriate antimicrobial use Mobilized FH antimicrobial utilization strategies and incorporated key measures from Provincial Clinical Care Management Built accountability with the Program Quality Performance Committees (QPCs) and incorporated the reporting of infection prevention and control KPIs through quarterly reports to the FH QPC and the FH Board of Directors Collaborated with Health & Business Analytics to launch a CDI/MRSA Surveillance Reporting Tool, available on the FHPulse, allowing for more timely dissemination of rates and number of cases by site, program, and unit. Drafted FH Housekeeping Standards for incorporation into the Infection Prevention and Control Manual Initiated Master Concept reviews for new builds and designed infrastructure audits to identify gaps in standards, such as optimal number and location of hand-washing sinks in single patient rooms In promotion of the relationship between increased hand hygiene compliance and decreased MRSA rates, FH continued to promote and monitor unit-led hand hygiene audits that are performed by front-line staff What improvement actions are planned for the next fiscal year? Physical, public posting of MRSA rates at FH sites and electronic access to rates on the FH public website Integrate MRSA data into the new automated CDI surveillance system Resume work with physicians and the Antimicrobial Stewardship Committee on antimicrobial stewardship and prescribing initiatives Persist with hand hygiene compliance improvement initiatives (see hand hygiene section) Work on a MRSA decolonization pilot in RCH ICU/HAU in an effort to review alternative approaches to controlling MRSA colonizations and infections Build a process for comprehensive review of the units with high MRSA rates and develop focused improvement initiatives for those units, similar to the CDI vulnerable units initiative Develop a general IPC refresher education policy and program for IPC best practices for all staff and physicians Page 21

22 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 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. In addition, FH participated in provincial planning and reporting of hand hygiene compliance. Status 3 Improvement Increase in compliance Target 80% compliance Actual (2012/13) 73% compliance Table 1. Hand Hygiene Compliance by Type of Fraser Health facility, fiscal year 2012/13 Residential Owned & Operated Mental Health & Substance Use Home Support/ Home Health JPOCSC/ Public Health/ Primary Care Fiscal Year 2012/13 FH Overall Acute Care Compliance 73% 72% 75% 68% 85% 81% Observations 103,752 86,578 12, ,440 Figure 7. Comparison of hand hygiene compliance by fiscal year in FH acute care sites 3 = 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; = problem area: actual is not meeting target and not meeting Canadian benchmarks. Page 22

23 Figure 8. Hand hygiene compliance among all staff by FH site, 2012/13 Figure 9. Hand hygiene compliance among all staff by FH program, 2012/13 (see Appendix F for # of observations by FH program) Page 23

24 Figure 10. Hand hygiene compliance by health care provider group for FH overall, 2012/13 Methodology: Hand hygiene audits are an ongoing performance measure across FH. A total of 103,752 hand hygiene observations were completed throughout fiscal year 2012/13 by trained and certified IPC Practitioners and healthcare providers on units. Observations were completed in various settings (with the exception of Residential Contracted facilities) 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. Multiple FH programs were audited. All auditors received standardized training and certification based on the hand hygiene audit toolkit available to all staff via the FHPulse. Auditors collected the hand hygiene observations on unit-specific 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 FH staff on the FHPulse. 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-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. Page 24

25 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 2012/13 annual target for hand hygiene compliance in FH was 80% and a goal of 100%. While FH did not meet the target, a compliance of 73% was achieved. Benchmark & Comparators: How does the rate compare to other areas? Public posting of provincial hand hygiene compliance rates for acute care sites began in 2012/13 and included 2011/12 compliance data. The 2012/13 acute care compliance in FH of 72% was slightly above the 2011/12 provincial compliance benchmark of 70%. Trend: What does the data show? A total of 103,752 hand hygiene practice observations were completed in 2012/13 across all of FH, accounting for a total compliance of 73% (see Table 1). Overall, FH hand hygiene compliance increased 13%, from 60% in 2011/12 to 73% in 2012/13. The acute care audits completed during fiscal year 2012/13 (86,578 observations) provided an overall FH compliance rate of 72%, which represented a 12% increase from the 2011/12 compliance rate of 60% (20,120 observations) and an increase of 66,456 observations (77%) (see Figure 7). FH Sites The FH sites with the highest hand hygiene compliance were FCH (84%), CGH (83%), and MMH (81%), all achieving above the FH target of 80% compliance for 2012/13 (see Figure 8). FH Programs The FH programs with the highest hand hygiene compliance were Public Health (88%), End of Life (86%), Home Health (85%), Rehab (84%), and Laboratory (81%), all which were above the 80% compliance target (see Figure 9). FH Health Care Provider Type The compliance by healthcare provider group in 2012/13 was 70% (13,073 observations) for clinical, 75% (79,753 observations) for nursing, 53% (4,508 observations) for other, and 57% (6,525 observations) for physicians (see Figure 10). 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. Page 25

26 The total number of acute care observations (N = 86,578) was significantly higher than in previous years; therefore, use caution 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. There was variance in the sites and programs included in hand hygiene audits during the years presented. 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. What actions have been taken over the last year? Implemented fiscal period frequency of routine hand hygiene audits for acute and residential care and provided immediate feedback forms highlighting compliance issues and providing improvement options Developed comprehensive hand hygiene certification materials and processes Developed and implemented an interactive, comprehensive hand hygiene audit and reporting system with efficient and effective audit performance, including simpler data collection and timely and comprehensive reporting for sites, programs, and units across FH (reporting available on the FHPulse). Worked directly with physician leadership to develop role modeling and other physician-led hand hygiene improvement strategies Chaired the Provincial Hand Hygiene Working Group Provided FH representation in the Provincial Evaluation, Infrastructure and Reporting Hand Hygiene Sub- Working Groups Enabled unit and site-specific hand hygiene posters for display in FH acute care sites Publically posted quarterly hand hygiene compliance posters for FH acute and Owned & Operated Residential Care facilities Launched a provincial hand hygiene policy, practice guideline, policy, and multi-level reporting, including a public provincial hand hygiene report through PICNet Revised the FH policy, clinical practice guidelines, and other related documents (e.g., Contact Precautions Plus signage) and education material to use ABHR if soap and water is not available Continued work with HSSBC and Health Pro to participate in national Request for Proposals (RFP) for hand hygiene contracts and products. Current provincial hand hygiene contracts expire June 2013 Continued to lobby HSSBC to supply FH with new ABHR products, as the current products and delivery design do not support point of care application Worked with housekeeping services at one facility to identify and number the hand hygiene brackets to aid in product refills and replenishment. This process for bracket identification will be implemented with new hand hygiene product installs Worked with various program to identify the 4 Moments for hand hygiene within their specifics of clinical practice and developed audit processes and improvement plans with them (e.g., Home Health, Public Health, Laboratory Services, Sterile Processing Department, etc.) Began to engage all levels of staff, leaders, and physicians in the development of facility and program-led improvement initiatives In collaboration with the Provincial Hand Hygiene Working group, designed a training/education program based on assessment of staff/leadership needs and perceptions from the 2012 provincial hand hygiene perception survey Page 26

27 Reviewed the 2012 hand hygiene perception survey to identify issues for FH and developed remediation and engagement plans for the organization (e.g., hand hygiene product availability, lack of time, lack of leadership from physicians, and other healthcare staff) What improvement actions are planned for the next fiscal year? Enhance the reporting and user functionality of the hand hygiene auditing and reporting system (FormAudit) Identify strategies to ensure hand hygiene guidelines are incorporated in appropriate clinical decision support tools Engage physicians in hand hygiene compliance leadership and role modeling Develop a process for evaluating new hand hygiene products available from newly approved vendors from Health Pro (ABHR, hand soap and lotion, and antimicrobial soap). Process evaluation to include the following categories: (a) ABHR user suitability and preference from LMH trial; (b) product specifications; (c) pricing of new products from the approved vendors; (d) transition of new products and ongoing support, education, and new products from vendors; and (e) future research endeavors from the approved vendors. Create and implement user suitability/preference trial at LMH for new ABHR products in collaboration with Facilities Management Organization (FMO) and Health Shared Services of BC (HSSBC) Write a business case for new products for FH and approval from Executive for choice of product and implementation Develop, plan, and implement new products across FH, ensuring robust, accessible, user friendly infrastructure and hand hygiene products across FH Design hand hygiene marketing and engagement plans and associated materials for use in improvement plans and organizational engagement strategies Initiate specific improvement plans and engagement work for hand hygiene compliance in conjunction with FH stakeholders at multi-levels across the organization (e.g., facility, unit, and program levels) as well as directly with front-line staff and physicians, patients, families, and volunteers. Establish and implement plan for World Hand Hygiene awareness day on May 6 th Engage facilities, units, programs, and all staff to complete the provincial hand hygiene perception survey Communicate findings from the results of the survey and use the findings to develop regional action plans for the organization Improve the current FH hand hygiene audit program (FormAudit) and dissemination of reporting to various FH audiences Expand audits to include (a) Residential Contracted facilities; (b) outpatient programs, such as Renal, other outpatient clinics, Maintenance and Pharmacy; and (c) the community sector, such as Home Health, Mental Health and Substance Use, and Primary Care. Develop and implement a process for physician hand hygiene audits and a feedback process in conjunction with physician leadership Review literature and plan for additional hand hygiene audits using alternative methodology Research and evaluate methods for prevention of ABHR consumption and theft in conjunction with Mental Health & Substance Use Services Page 27

28 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 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 4 Improvement Increase in Compliance Target> 95% Compliance (high-risk areas) Actual (2012/13) 87% Compliance Increase in Compliance 85% (low-risk areas) 93% Compliance Figure 11. Reprocessing compliance by year for FH new audit tool implemented in 2012/13 ^ includes JPOSC * includes residential care sites except in 2010/11 Audit. 4 = 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; = problem area: actual is not meeting target and not meeting Canadian benchmarks. Page 28

29 Figure 12. Reprocessing compliance in high-risk areas (SPD & OR), 2012/13 implemented new audit tool in fiscal year 2012/13, includes JPOCSC (see Appendix G, Table G1 for compliance results for high risk areas) Figure 13. Reprocessing compliance for low-risk areas, FH community sector, 2012/13 implemented new audit tool in fiscal year 2012/13 includes one renal audit (see Appendix G, Table G2 for compliance results for low risk areas, FH community sector) Page 29

30 What is being measured? A standardized provincial audit tool is being used to measure compliance to reprocessing best practice standards that includes 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. 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, or use of medical devices, are audited according to the risk classification (of the steps undertaken within that program). 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 three-year 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, RCAL, MHSU 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? In 2012/13, the SPD and OR areas classified as high risk had a total compliance of 87%, which was below the target of 95%. The remaining community areas classified as low risk had a total compliance of 93%, surpassing the target of 85% compliance. 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 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. Trend: What does the data show? A new audit tool was implemented for FH in fiscal year 2012/13, making comparisons from previous years inappropriate, as the audit questions are dis-similar and the questions have been expanded upon. This year, due to the delay in filling vacancies within the Reprocessing ream, only the SPD and OR units were audited among acute care sites with the inclusion of JPOCSC. The compliance ranged from a high of 93% at JPOCSC to a low of 79% at RCH. Among the low-risk areas in community sites, residential care (i.e., HSP-contracted sites achieving an astounding 99% compliance) with primary care having the lowest compliance at 70%. Page 30

31 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 preemptively identified high-risk equipment and requested information about the reprocessing of these items. As year four is being initiated, reprocessing of specific equipment is being evaluated and work is being completed to standardize reprocessing steps to meet industry 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 Mental Health & Substance Use sites. Next fiscal year, FH is adding Facilities Management and Operations as well as Procurement, Stores, and Warehousing. Comments: There are FH-wide initiatives underway that are considered regional in scope that are being remediated by the FH reprocessing team, not by the individual programs or sites. FH auditors applied standardized answers to some of the questions as an FH regional responsibility. Examples include development of an FH-wide policy for purchasing and dissemination of the education requirements created for the SOPs. 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 supported by FH. These regional initiatives do 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. What actions have been taken over the last year? Implemented a collaborative team approach with IPC and HSSBC/HealthPro with the commencement of a Procurement Consultant for the purchase of items. The intent is to standardize purchasing steps to improve capacity to meet reprocessing standards (e.g., changed to disposables where reprocessing is impractical, or redesigned work flow and equipment inventory levels to shift work to SPDs, or initiated on-unit reprocessing/disposal of human waste containers to reduce the workload in SPD) Re-organized the three-year audit plan for FH. Annual audits of high-risk areas (any unit that pre-cleans, cleans, or uses high-level disinfects and/or sterilizes) including MDRD, ORs, EDs, MICY, Respiratory, as well as a sampling of low-risk areas from each program. Over a three-year period, all low-risk areas will be audited Developed an electronic audit and reporting tool to support audit of data collection, feedback, and reporting function for areas audited Completed approximately 50 reprocessing audits this fiscal year Continued improvement initiatives from previous audits of critical and semi-critical medical devices, including: (a) evaluation of storage areas for medical devices and patient care equipment; and (b) expansion of reprocessing requirements to encompass non-critical medical devices and support services such as FMO, Procurement, and Warehousing Soiled utility room reviews undertaken based on site requests Updated the FH Quality Assurance Reprocessing Plan; submitted plan to MoH Worked with the Provincial Reprocessing group and the MoH to adopt the FH-created education material, including curricula and evaluation criteria for use provincially Page 31

32 Developed process templates for creation of work instructions (WIs) for all medical devices within FH that incorporate the equipment s Material Safety Data sheets (MSDs) and the Manufacturer s Instructions for Use (MIFUs) Worked with engaged stakeholders to begin education for unit/program creation of work instructions (WIs) by filling out templates Collaborated with HSSBC and BC MoH to begin development of FH purchasing policy Worked with the Provincial Reprocessing Working Group to standardize processes and practices across the province with review of critical incidents (through PSLS) that influence risk evaluation of reprocessing practices Participated on Provincial Reprocessing Working Group document development, review, and revision. What improvement actions are planned for the next fiscal year? Communication and review the MoH-mandated reprocessing three-year audit plan, risk matrix, and stakeholder feedback with FH Clinical Executive Directors and other stakeholders Review and follow-up on outstanding high risk remediation responses from year one(1) (2012/2013) audits Completion of all planned for Year 2 (2013/2014) audits Report to FH Executive and the MoH on Year 1 audit compliance results Develop a process for review and evaluation of all soiled utility rooms across FH acute care facilities to ensure they meet IPC standards for workflow and best practices Report back to appropriate program leadership and stakeholders for follow-up and remediation planning with escalation of budgetary requirements Focus effort on soiled utility room assessment and remediation: vulnerable units at high risk or case load for CDI Create a process to review current status and determine gap analysis with stakeholders of macerator/ disinfector needs across FH acute care sites/units Generate best practice recommendations regarding human waste disposal workflow and choice of macerator/ disinfector for use within FH acute care units, both for renovations and new builds Provide support for new human waste disposal installs and renovations based on priority for vulnerable units at high risk or case load for CDI Communicate and review unique components that impact Clinical Executive Directors and other stakeholders from the IPC MoH-mandated QA framework Engage stakeholders in the development and implementation of the three-year QA reprocessing action plan across FH. Develop education framework and plan for reprocessing education modules for (a) site leadership, (b) frontline staff, and (c) physicians across FH acute care and community programs Develop evaluation and sustainment plan for the reprocessing education and audits Focus education in 2013/2014 on high risk reprocessing areas: (a) Sterile Processing Department, (b) Operating Rooms, (c) Respiratory Therapy program, (d) Ambulatory Day Care, and (e) Diagnostic Imaging. Work with the BC MoH to create college-level curriculum for Reprocessing of Medical Devices Support units to complete work instructions for all medical devices within FH using an approved template that incorporates the Material Safety Data sheets (MSDs) and the Manufacturer s Instructions for Use (MIFUs) Build and provide a library for all reprocessing work instructions for the organization, including medical devices, MIFUs, and risk categories (level of reprocessing required) Page 32

33 Prioritize creating WIs for vulnerable units presenting high rates for nosocomial CDI Support units to complete work instructions for all medical devices within FH using an approved template that incorporates the MSDs and the MIFUs Participate in all Provincial Reprocessing Working Group document developments, reviews, and revisions Outbreak Management Gastrointestinal Illness Outbreaks Figure 14. Comparison of Gastrointestinal illness outbreaks in acute and residential care facilities by type of outbreak, fiscal years 2011/12 & 2012/13 Note: Scenario A/B outbreaks only Page 33

34 Figure 15. Gastrointestinal illness outbreaks in acute and residential care facilities by month, 2012/13 Note: Scenario A/B outbreaks only Figure 16. Gastrointestinal illness outbreaks in acute and residential care facilities by FH city, 2012/13 Note: Scenario A/B outbreaks only Page 34

35 Table 2. Etiological Agents Identified from Declared Gastrointestinal Illness Outbreaks in FH, Fiscal Year 2012/13 Facility Type Norovirus CDI Noro/CDI Rotavirus Unknown Aeromonas No Neg veronii test Total Acute Care Res Care - O&O Res Care - HSP Contracted Grand Total Note: Scenario A/B outbreaks only What is being measured? The total number of GI outbreaks and their impact on acute care and residential (res) care [Health Service Provider Contracted (HSP-contracted) and Owned & Operated (O&O)] sites in FH, including the outbreak etiology, total number of outbreaks declared, and the month and city associated with outbreak declaration. Methodology: Surveillance and management of acute care and res care O&O outbreaks is completed 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 a standardized case definition to determine if a GI outbreak should be declared (i.e., three or more cases of gastroenteritis in patients or staff in a four-day period). There are standardized GI outbreak management protocols for both acute and residential care sites. Acute and res care O&O outbreaks are reported through a GI outbreak investigation notification (GION) system, which includes an FH-wide posting of all outbreaks that have commenced and been declared over. Surveillance and reporting of res care HSP-contracted sites is completed by Public Health. IPC Practitioners monitor and record all acute care and res care O&O outbreaks in an FH internal database. Public Health monitors and records all residential HSP-contracted sites. C.difficile Infection Outbreak Reporting The IPC program declares and reports CDI outbreaks in acute care sites. FH is the second health authority to declare CDI outbreaks following VIHA s lead. However, FH and VIHA do not have one standardized definition so outbreak numbers are not comparable. 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. Trend: What does the data show? In fiscal year 2012/13 (Apr 1/12 Mar 31/13), there was a total of 79 GI outbreaks declared in FH; 39 outbreaks in acute care sites, 10 outbreaks in res care O&O sites, and 30 outbreaks in res care HSP-contracted sites (see Figure 14). Among acute care facilities, there was an increase in GI outbreaks from 34 outbreaks in 2011/12 to 39 outbreaks in 2012/13. Notably, there were fewer mixed norovirus/cdi outbreaks in 2012/13 due to improved identification by laboratory confirmation as to the type of outbreak occurring. Norovirus and C.difficile infection outbreaks often Page 35

36 coincide, as increased norovirus activity increases diarrheal symptoms among patients, which may prompt testing of liquid stool and discovery of patients who have C.difficile, impacting declarations and duration of outbreaks. The number of outbreaks in res care O&O and HSP-contracted sites were relatively similar for the past two fiscal years (see Figure 14). Although consideration should be given that with world-wide travel, boundaries around seasonality of infections become blurred, the majority of GI outbreaks occurred during the lower mainland typical norovirus season between October 2012 and March 2013 (see Figure 15). At the beginning of fiscal year 2012/13, which corresponded to the end of the prior norovirus season, acute care experienced a number of outbreaks, which may account for the increased total in 2012/13 (see Figure 15). The regional distribution of GI outbreaks in FH indicates higher activity in the major city centres of Surrey, New Westminster, and Abbotsford (see Figure 16). This effect may be the result of the population density and number of facilities in these regions. A total of 44 outbreaks were confirmed Norovirus across all types of FH sites; 14 outbreaks were exclusively attributed to CDI, and six outbreaks were mixed norovirus and CDI in acute care sites. A large number of outbreaks were of unknown source. A Rotavirus outbreak and an Aeromonas veronii outbreak occurred in two separate res care HSP-contracted sites (see Table 2). Limitations: Details regarding management of outbreaks in different types of sites is not well known and could impact the duration of an outbreak and number of people that are affected. What actions have been taken over the last year? Developed a comprehensive set of GI clinical decision-support tools including a new GI policy, an associated GI outbreak management clinical practice guideline, support material and standardized communication tools and contact lists for outbreak situations, audit tools for site leadership and front line staff, and corresponding education material Supported GI education for front-line staff Introduced an escalated series of GI-enhanced cleaning protocols in collaboration with contracted housekeeping services, including specific outbreak management cleaning protocols Implemented enhanced cleaning in FH acute care Emergency Departments during the influenza and GI season Posted all acute care GI, CDI, and Respiratory Illness (RI) outbreaks on the external FHPulse page for public viewing and information Published the outbreak recommendations and lessons learned in the FH IPC annual report and on the FHPulse page for IPC What are the outbreak recommendations and most important lessons learned from the 2012/13 outbreaks? 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 "alerts" 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 "wandering patients" when starting and maintaining outbreaks Page 36

37 The importance of frequent sporicidal disinfection of staff and public 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 for the duration of outbreaks What improvement actions are planned for next fiscal year? Continue to provide support, expertise, and education for the FH acute care sites on the new GI policy, clinical practice guidelines, and support and communication tools. The education will be multifaceted and multimodal in order to engage as many staff and physicians as possible in the education modules. Develop fall GI and Flu schools for acute care similar to the model used by Residential Care and Public Health Programs that will identify and remind staff of key IPC best practices and protocols to be followed during the GI and Influenza outbreak season (traditionally from November through to March/April) Review all FH outbreaks to determine lessons learned, and incorporate learnings back into revision of the GI documents and education material Develop a standardized review tool for evaluation of each outbreak Publish the Outbreak recommendations and lessons learned in the FH IPC annual report and on the FHPulse page for IPC. Respiratory Illness Outbreaks Figure 17. Comparison of respiratory illness outbreaks in acute and residential care facilities by type of outbreak, fiscal years 2011/12 & 2012/13 Note: Scenario A/B outbreaks only Page 37

38 Figure 18. Respiratory illness outbreaks in acute and residential care facilities by month, 2012/13 Note: Scenario A/B outbreaks only Figure 19. Respiratory illness outbreaks in acute and residential care facilities by FH city, 2012/13 Note: Scenario A/B outbreaks only Page 38

39 Table 3. Etiological Agents Identified from Declared Respiratory Illness Outbreaks in FH, Fiscal Year 2012/13 Facility Type Influenza A A/ Coronavirus A/ RSV RSV Coronavirus hmpv Neg No Test Total Acute Care 4 4 Res Care - HSP Contracted Res Care - O&O Grand Total Note: Scenario A/B outbreaks only What is being measured? The total number of RI outbreaks and their impact on acute care and res care sites in FH (i.e., HSP-contracted and O&O), including the outbreak etiology, total number of outbreaks declared, and the month and city associated with outbreak declaration. RI Scenarios A and B are being measured. Scenario A is confirmed influenza, and Scenario B is serious illness not influenza. Methodology: Surveillance and management of all acute care and res care O&O outbreaks is completed by IPC Practitioners and entered in a FH internal database. IPC Practitioners are notified of symptoms consistent with RI by front-line staff and use a standardized respiratory outbreak case definition to determine if a respiratory outbreak should be declared (i.e., two or more staff/residents with new or worsening cough in a unit or area within a seven-day period). There are Standardized Infection Control respiratory outbreak management protocols for acute and residential care sites. RI 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 included in surveillance. Acute care and res care O&O outbreaks are reported through a respiratory outbreak investigation notification (RION) system, which includes an FH-wide posting of all outbreaks that have commenced and been declared over. Surveillance and reporting of HSP-contracted res care sites is completed by FH Public Health and the Population Health Assessment Team. Trend: What does the data show? In fiscal year 2012/13 (Apr 1/12 Mar 31/13), there were a total of 46 RI outbreaks declared in FH; four outbreaks in acute care sites, 15 outbreaks in res care O&O sites, and 27 outbreaks in res care HSP-contracted sites (see Figure 17). Acute care sites experienced an increase in RI outbreaks from the prior fiscal year, as there were none during 2011/12. Res care O&O sites also reported an increased number of RI outbreaks, from only four during fiscal 2011/12 to 15 during fiscal 2012/13 (see Figure 17). Res care HSP-contracted sites increased tremendously during fiscal year 2012/13, with 27 confirmed influenza outbreaks compared to only two confirmed influenza outbreaks the prior fiscal year 2011/12 (see Figure 17). A large number of RI outbreaks occurred during January 2013, with the remainder during the typical influenza season of November 2012 to March 2013 (see Figure 18). Burnaby had the highest number of RI outbreaks among FH cities, followed by Langley and White Rock (see Figure 19). Interestingly, the RI outbreak distribution differs from the GI outbreak distribution (see Figure 16). Page 39

40 A total of 33 outbreaks were confirmed influenza A across all types of FH sites (see Table 3). Acute care facilities had exclusively influenza A outbreaks, while res care facilities additionally reported RSV, Coronavirus, and Human Metapneumovirus (hmpv). Some outbreaks were of unknown source (see Table 3). 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. Comments: There was one Scenario C respiratory outbreak in an O&O-operated facility. No ward closure occurred, and only three residents were affected. What actions have been taken over the last year? Provided Flu Schools pre-influenza season to res care, both HSP-contracted and O&O res care sites, and Mental Health sites in conjunction with Public Health, Infection Control, and Workplace Health Conducted a survey to determine the usability of the new respiratory outbreak protocol implemented in fiscal 2009/10 Provided support and debriefing sessions to residential care sites during and after the respiratory outbreak season respectively A new Fluad vaccine was introduced for residents in FH sites Implemented the new provincial influenza vaccine policy What improvement actions are planned for the next fiscal year? Continue providing annual flu schools to inform staff and provide details about any changes to the respiratory protocol and the influenza vaccine, as well as provide a review of last year s outbreaks. These flu schools are done by the Medical Health Officer, Communicable Disease Nurse Coordinator, Occupational Health, and the Residential IPC Practitioner Continue providing debriefing sessions at HSP-contracted res care sites Evaluate the results of the respiratory outbreak protocol survey, establish recommendations from the survey, and take action Page 40

41 IPC Program FH Strategic Initiatives INFECTION PREVENTION AND CONTROL A focus on patient safety The first part of the report is but a brief glimpse into the activities of the IPC Program staff and their efforts to promote infection prevention through the surveillance of HAIs. The IPC program would like to highlight the many other aspects of infection prevention related to facility design, product selection, education, policy/process formulation, preventive measures during construction, and such, in which the program is involved (see Table 4). Table 4. IPC Program Strategic Initiatives STRATEGIC INITIATIVES IPC Strategic Work Plan Housekeeping Hand Hygiene IPC Best Practices Hospital Acquired Infections (HAI) surveillance and methodology IPC Human Resources IPC Professional Development Construction KEY COMPONENTS IPC Strategic Work Plan FH Housekeeping manual Alignment with FH-contracted housekeeping service vendors Education for new manual and cleaning requirements Library of chemicals used by housekeeping vendors Integrated audit processes for cleaning processes PICNet provincial group membership BISS involvement for stakeholder feedback Hand hygiene products evaluation and implementation across FHA Hand hygiene engagement and improvement work for staff, physicians, patients clients and visitors Provincial hand hygiene perception survey implementing an action plan Hygiene audits and feedback improvement and expansion of current audit program Complete a hand hygiene research project Ongoing work and participation with Provincial Hand Hygiene Working Group Carbapenum-resistant Enterobacteriaceae (CRE) TB surveillance and consultation from an internal FH team of physicians, IPCs, and Workplace Health & Safety Automated surveillance tool Carbapenum-resistant Enterobacteriaceae (CRE) review Antimicrobial stewardship Automated delivery of IPC performance metrics reports (see Appendix E) Improvement of Statistical Process Control (SPC) Charts for HAIs Off-the-Shelf (OTS) IPC surveillance and alerting program Central line blood stream infections, ventilator- associated pneumonias, and surgical site infections VRE evaluation Enhanced IPC Practitioner/Consultant program model Enhanced medical support for IPC across FH Education pathway for IPC Practitioners and Consultants IPC link nursing program Performance link and professional competencies IPC education pathway for healthcare professionals IPC Education Consultant IPC course at BCIT IPC Construction Manual Page 41

42 STRATEGIC INITIATIVES IPC Strategic Work Plan Purchasing/ Procurement Projects KEY COMPONENTS IPC Strategic Work Plan Capital planning, footprint, functional programming, RFP, blueprints, and design Infection Control Construction Agreements (ICRAs), reviews of construction and renovation projects Lower Mainland Consolidation (LMC) Committee for Facilities Management and IPC Construction education for practitioners/facilities RFP, bids, tender processes Template development and transparent review process for evaluation of medical devices prior to purchase Purchasing policy development HSSBC and HealthPro relationships MRSA RCH ICU hand hygiene/ decolonization TB testing platform Room decontamination Fecal transplants OR dehumidification Housekeeping cleaning evaluation Soiled utility room gap analyses ABHR consumption by Substance Abuse Clients FH Housekeeping Standards for incorporation into FH Infection Prevention and Control Manual Page 42

43 Education The IPC team provides all relevant IPC 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. Types of education provided by IPC Practitioners include: Workshops + Presentations New Employee Orientation Hand Hygiene Reprocessing of Medical Devices Construction Influenza + Immunizations Tuberculosis Clostridium Difficile Outbreaks: GI, Respiratory Routine Practices Transmission-Based Precautions Antibiotic Resistant Organisms Safety Huddles, In-services, Family Support Consultations with Public Health and Third-Party Providers Internships and Mentorships for Students Mentorship of New IPC Practitioners Educational resources such as the Hand Hygiene, MRSA and CDI pamphlets for patients and families are updated as needed to ensure recommendations are based on current evidence-based industry standards and guidelines. This year, IPC Practitioners also began the task of reviewing and rewriting portions of the Infection Control Manual and are committed to updating essential sections every three to five years. Education for FH healthcare providers has expanded to on-line modules readily accessible through the FHPulse for orientation and hand hygiene. Further, education modules have also been provided on the FH intranet to ensure all staff in various areas can access. Additional modules/manuals/guidelines are currently under development for the standardization of roles, responsibilities, and expected outcomes for both Environmental Controls and Construction. These will hopefully be completed in final versions by spring of All IPC Practitioners participate on regional committees such as Professional Practice, Environmental, Residential Care, Blood and Body Fluid, Joint Workplace Health/Public Health/IPC as well as QPCs for the program(s) they cover. Page 43

44 Competencies, Certifications, and Membership The leadership team remains committed to augmenting competencies and expanding the expertise in the team. We are proud to announce that a number of our IPC Practitioners have committed their personal time to advance their education in the field of Infection Prevention and Control. Congratulations to Sebastien Dorais, Noorsallah Esmail, Amira Imamovic-Buljubasic, Vlada Abed, and Shelly Garcha for working hard towards their Certification of Infection Prevention and Control through UBC. Additionally, Amanda Giesbrecht has been working towards completion of her Basic Infection Control Certificate through the Community and Hospital Infection Control Association of Canada. Congratulations to Pat Bleackley, who continues to maintain her Certification in Infection Control. Commitment to expansion of infection prevention and control certification has also been endorsed. Leadership supports a bi-monthly webinar series through Webber Training and PICNet BC for IPC Practitioners. Additionally, four IPC Practitioners were supported to complete Certification of CSA Construction Standards both the fundamentals of Infection Control during construction as well as the advanced course. Congratulations to Lauren Kim, Sebastien Dorais, Amanda Giesbrecht and Janice Cook for completing the courses. Moreover, membership to the Canadian Healthcare Engineering Society for the support of construction in healthcare has been achieved by Jan Verbeck, Darlene Spence and Sandra Daniels. Additional support has been granted to advance leadership skills and knowledge. Tara Donovan and Sandra Daniels were supported through the FH Management Development Pathway developed by Harvard Business. Additionally, Lauren Kim completed the FH Clear Leadership course. The IPC program employees are members of CHICA-BC. Additionally, executive positions for the CHICA-BC chapter were held by FH IPC staff including: Jacquie Hlagi, president-elect and president; Tara Donovan, treasurer and president-elect; and Janie Johnson, membership secretary/webmaster. Additionally, FH IPC Practitioners provided membership on a number of the CHICA subcommittees and interest groups, and Tara Donovan is co-chair of the CHICA Surveillance and Applied Epidemiology Interest Group. Page 44

45 IPC Program FH Strategic Initiatives INFECTION PREVENTION AND CONTROL A focus on patient safety 1. Great Workplaces a. Improving wellbeing b. Supporting feedback c. Retention and recruitment d. Professional development Performance Link 2. Quality and Safety a. Reprocessing of medical devices b. Clostridium difficile infections initiatives c. Redevelopment and renovations of soiled utility rooms d. Hand hygiene e. Development of process for mattress review and replacement f. Catheter Associated Urinary Tract Infection work 3. Research and Development a. Evidenced-based practice development for gastrointestinal illnesses policy and clinical and environmental services clinical practice guidelines (CPGs) b. Outbreak management c. Chart reviews and risk assessments for patients with poor outcomes with AROs or CDI d. Translate knowledge into action 4. Capacity a. Expanding team i.e. increase numbers of FTEs of both site-based practitioners and regional consultants b. Supporting construction projects c. Proposal for Meiko (washer/disinfector) installations d. Development of Information Technology infrastructure 5. Progressive Partnerships a. SHAIPE collaborative b. National Surveillance Quality Improvement Program c. BC Ministry of Health d. Qmentum/Accreditation Canada e. PICNet f. Provincial Infection Prevention and Control Committee Page 45

46 Summary of Initiatives Great Workplaces INFECTION PREVENTION AND CONTROL A focus on patient safety 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 measure the level of engagement staff members have with their job and the organization. The leadership team is committed to improving job satisfaction and has developed and initiated a plan to promote competencies and 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. The leadership team has also committed to providing financial support to advance the professional development of our employees. The leadership team supports up to nine days of paid leave for education purposes that support the IPC Practitioner and consultant selfdirected development. The leadership team has also approved various conferences and in-services and has supported the IPC Practitioners to lead and promote education of interest to them. PerformanceLink for the consultant positions is in place and is being developed for the practitioners. Staff members have been encouraged to rotate the chairing of the monthly IPC team meetings, which will enable them 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. Quality Improvement and Patient Safety Initiatives Based on a provincial directive from the BC MoH, FH initiated Reprocessing SOPs, which were completed in April Since that time, the BC MoH created an expert team from BC to redevelop the PIDAC (Ontario) Best Practice Guidelines for Reprocessing Critical and Semi-Critical Medical Devices. FH supported the expert team with two members from IPC, and the guidelines have been published. Additionally, this year, the BC MoH has created an expert team to develop the education requirements for practitioners and clinicians who reprocess medical devices. The group has agreed to adopt FH s education modules developed last year. The modules, which will be supported via Course Catalogue Registration System (CCRS), are currently under development. An 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 The FH audit tool was restructured in 2011 to improve efficiencies in real-time reporting. After an audit, compliance reports are distributed to the manager. While the program was instigated by the IPC team, it is recognized that hand hygiene should be owned by all. We continue to engage multiple program-based auditors to support units and develop unique plans for improvement. 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 is to reduce the rates of nosocomial CDI cases. Action teams continue to bring tools and resources together to individualize change initiatives such as environmental services, including reprocessing of medical devices and housekeeping requirements as well as antibiotic stewardship. We continue to incorporate hand hygiene audits and IPC Practitionergenerated 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. Some sites have also begun creation of mattress review tools and processes for Environmental Services and clinical staff to determine the life cycle of a mattress and determine processes for identification and replacement of damaged mattresses. Catheter-Associate Urinary Tract Infection (CAUTI) work continues to expand to other hospitals within FH. The recommendations from the IPC Practitioners include assistance with determining the indications for catheter use as well as supporting the high-risk for CAUTI programs with education and guidance. Page 46

47 Research and Development IPC Practitioners and Consultants conduct research based on the most up-to-date, published research. The goal is to make this information available and support the integration of evidence into practice. This is done through reconstruction and dissemination of the updated sections within the IPC manuals as well as provision of inservices, presentations, and consultations. This year, the team created new sections missing from the IPC Acute Care Manual that support the management of CDI and other GI illnesses, such as the GI policy and clinical practice guidelines. IPC Practitioners are also committed to translating knowledge into practice. Examples of development of processes that support IPC initiatives include (a) development of audit tools for GI, such as soiled utility audit, risk assessment, and case management tools for nosocomial CDI cases (i.e., the de-clutter tool). These tools were created to support the clinical staff members in determining gaps in processes. The team also began the process for outbreak management and continues to develop the process map. The team has recently developed chart review tools for patients with poor outcomes and is following up cases. Capacity FH Executive, with the support of the BC MoH, has approved expansion of both the numbers of FTEs as well as an expansion of hours of coverage. This commitment to expansion of the program supports a net increase of 15.5 FTEs. Over the last year, an additional 5.5 FTE practitioner positions have been created, 2.0 FTE manager positions have been added, plus three vacation-relief positions and additional casual positions. Over the last year, we have posted and filled nine positions for site-based practitioners. We have an additional six vacancies we are committed to filling next fiscal year. Additionally, we created capacity within the program to complete projects with new regional consultant positions that we have filled with nine FTEs, with a focus on regional quality improvement initiatives and projects. Capacity within the program has also been created with recruitment of a Construction Consultant. The intent for this role is to support the IPC team for new construction at the Master Concept Planning, Design, and Commissioning phases, as well as determining FTE requirements for projects. The following is a list of some of the major construction projects worked on in : Yale Road Centre Senior Living Surrey Tower Construction and Service Review Panorama Ridge Haemodialysis Unit Royal Columbian Tower Project Master Concept Planning Additionally, IPC Practitioners provide support and guidance for other projects and deficiencies such as: Floods: Most of the FHA facilities are aging, and over time, problems with pipes leaking or rupturing causing facility damage increase. Additional education was required for an expanded selection of the site-based practitioners. The leadership was able to create additional capacity within the team by purchasing additional guidelines and expanding education for CSA certification. 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. Increase need for sterile supply storage space, redesign of soiled utility rooms with installation of washer/disinfectors or macerators to meet standards, improve capacity on units and improve patient safety, and reduce the risk for disease transmission. Page 47

48 Progressive Partnerships Collaborative partnerships external to FH are supported through IPC team members working with the BC MoH, the Provincial Infection Control Network (PICNet), Canadian Standards Association, and Accreditation Canada as well as Lower Mainland Consolidation (LMC) committees and provincial working groups for development of consensus documents and standardized practices and processes. These initiatives include Hand Hygiene, Reprocessing of Medical Devices, Environmental Services, Lower Mainland Consolidation (LMC) Facilities Management, and the IPC Collaborative for Construction. The leadership group has developed a Quality Assurance Plan for Infection Prevention and Control as well as focusing on reprocessing and is creating a work plan for stakeholder evaluation of internal collaborations and partnerships. The leadership team is committed to completing this process next fiscal year. Please see Appendix H for a list of terminology and abbreviations found in the text which are not always explained each time they occur. Page 48

49 Appendices Appendix A: Dr. Michael Gardam Report Recommendations and Completed Actions RECOMMENDATIONS 1. Either alcohol based hand rub (ABHR) or soap and water is acceptable for patients with CDI. 2. Differentiation between Program and facility accountability for CDI 3. IPC program under - resourced 4. Environmental cleaning initiatives COMPLETED ACTIONS 2012/2013 Revised the FH Policy, clinical practice guidelines and other related documents (e.g. Contact precautions Plus signage) and education material to use ABHR if soap and water is not available. A regional department of infection prevention and control and public health was created and is headed by the new Executive Medical Director for Infection Prevention and Control, Dr. Elizabeth Brodkin. A new IPC governance model was designed to reflect local and FH accountabilities for sites and intersections with IPC and other programs. A Head of Department (local) is being appointed for each site in accordance with the Medical Staff Rules and will co-chair the local IPC Committee (LIPCC) with the Site Director. A new model for IPC has been developed. The IPC program infection prevention and control practitioners (IPCPs) will have facility level day-to-day reporting responsibilities to the Site Director. There are clear accountabilities for Site Directors who have a facility managerial responsibility for infection prevention and control issues - including CDI and hand hygiene and other IPC communicable disease issues. Site Directors have the authority and responsibility to ask programs and other support services (e.g. housekeeping) for their audits, improvement action plans. The professional practice of IPC is centralized to ensure standardization of practice through a professional practice council positions were added to the IPC program for 2012/2013, plus one additional manger position. A new IPC staffing model and organization chart were developed and implanted that included new reporting roles and responsibilities utilizing existing IPC Practitioners to provide facility-level operational support and IPC Consultants to support regional programs and key organizational initiatives. The new model provides coverage for evenings and weekends across acute care sites to ensure comprehensive coverage by Infection prevention and control practitioners. The IPC consultant role includes 3 Quality Improvement and Patient Safety consultants to assist with organizational behavior change and system wide improvement initiatives. Conducted full facility enhanced cleans at 6 FH acute care sites that have the highest rate of CDI in 2011/12 and 20123/2013 (using 5000 ppm bleach solution twice per day 6 8 hours apart) In collaboration with BISS and FH P3 partners, implemented an escalating series of enhanced cleaning protocols for all GI cases across the FH acute care sites. This includes each GI case room on each unit, alert level cleaning for the entire unit when the unit experiences increased transmission or reaches a high bioburden level (> 10% of patients on the unit with CDI), and outbreak cleaning (similar to an alert level clean but unit is closed for admission and transfers). Implemented a special Emergency Department enhanced clean during the influenza season. Page 49

50 RECOMMENDATIONS 5. Antimicrobial Stewardship Program 6. ABHR dispensers at pointof-care (POC) 7. Publicly report hand hygiene, CDI and MRSA rates. 8. Engagement of front line staff with the improvement work and action teams 9. Dirty utility room set-up and work flow 10. C. difficile toxin versus PCR testing COMPLETED ACTIONS 2012/2013 IPC assisted in the development of the FH Antimicrobial Stewardship program and initial review of antimicrobial issues across FH. AMS Committee initiated the Automatic Stop policy for antimicrobials across FH. FH AMS committee collaborated with the provincial group to develop a document for review of antimicrobial best practices: Antimicrobial Stewardship: Review of Best Practices. The best practices are under for consideration for adoption for FH. Hired Dr. Chris Wong, Regional Division Head for Infectious Diseases has agreed to become the Chair of the newly formed FH Antimicrobial Stewardship Committee. Worked with HSSBC and Health Pro to develop RFP for new hand hygiene products across FH which includes point-of-care brackets. Worked with housekeeping services at one facility to identify and number the hand hygiene brackets to aid in product refills and replenishment. This will be implemented with new hand hygiene product installs. Developed process for public posting of hand hygiene rates quarterly by facility and each fiscal period on units in FH acute care sites and Residential Owned and Operated facilities. Developed process for public posting of CDI rates on each FH acute care unit each fiscal period. Develop process and tools for posting CDI and MRSA rates on the FHPulse page each fiscal period. Developed new IPC program structure including IPC quality consultant role that will support the culture and behavior change for programs regarding adoption of strong infection prevention and control best practices and protocols. Developed new GI policy, clinical practice guidelines, CDI case review protocols and improvement plans for use with the IPC Practitioners at the site and the IPC Consultants through a regional and program lens. Developed and initiated an action plan for the evaluation and remediation of soiled utility room workflow across FH facilities. Work will continue into next fiscal year. Completed the transition from a cytotoxin assay test to PCR-based testing at all FH sites. 11. Review VRE policy FH discontinued VRE screening and isolation requirements at FH facilities. Developed a surveillance plan to track VRE infections and outcomes quarterly to monitor the impact of the change on patient safety 12. Revisit existing housekeeping contracts, continue external audits, engage housekeeping staff in CDI initiatives Developed process to engage and work with housekeeping services on improvement initiatives with facility and unit based improvement work. 13. Individual CDI case review Developed automated process for conducting individual CDI case reviews using online surveillance data as well as manual entry from IPC Practitioner conducting a chart review. Trialed the CDI case review with a number of cases that experienced unexpected or poor outcomes and provided feedback to the unit leadership on the case review and potential findings. Page 50

51 Appendix B: Structure and Accountability for IPC Program Page 51

52 Appendix C: IPC Program Organization Chart Page 52