Infection Control Resource Teams The First Five Years

Infection Control Resource Teams The First Five Years A Review and Analysis of the Recommendations Made to Hospitals for Clostridium difficile Infection (CDI) Outbreaks February 2017

Public Health Ontario Public Health Ontario is a Crown corporation dedicated to protecting and promoting the health of all Ontarians and reducing inequities in health. Public Health Ontario links public health practitioners, front-line health workers and researchers to the best scientific intelligence and knowledge from around the world. Public Health Ontario provides expert scientific and technical support to government, local public health units and health care providers relating to the following: Communicable and infectious diseases Infection prevention and control Environmental and occupational health Emergency preparedness Health promotion, chronic disease and injury prevention Public health laboratory services Infection control resource teams are available to support hospitals and other health care settings during outbreaks particularly Clostridium difficile infection outbreaks. These teams consist of physicians, infection prevention and control practitioners, and epidemiologists who have expertise in outbreak management and infection prevention and control. The teams are deployed on request by either the local public health unit or health care setting to review the current status of the outbreak and provide recommendations for systemic improvements. Public Health Ontario s work also includes surveillance, epidemiology, research, professional development and knowledge services. For more information, visit Public Health Ontario. How to cite this document: Ontario Agency for Health Protection and Promotion (Public Health Ontario). Infection Control Resource Teams The First Five Years. A Review and Analysis of the Recommendations Made to Hospitals for Clostridium difficile Infection (CDI) Outbreaks. Toronto, ON: Queen s Printer for Ontario; 2016. ISBN: 978-1-4606-8647-8 Public Health Ontario acknowledges the financial support of the Ontario Government. Queen s Printer for Ontario, 2017 Infection Control Resources Teams First Five Years i

Authors Camille Achonu, MHSc Epidemiologist Lead Infection Prevention and Control Public Health Ontario Isabelle Langman, RN, CIC IPAC Specialist Infection Prevention and Control Public Health Ontario Jennifer Robertson, PhD Manager, Knowledge Synthesis and Evaluation Infection Prevention and Control Public Health Ontario Grace Volkening, CIC IPAC Specialist Infection Prevention and Control Public Health Ontario Liz McCreight, CIC Manager, IPAC Resources Infection Prevention and Control Public Health Ontario Cathy Egan MBA, CPHI(C), CIC Director Infection Prevention and Control Public Health Ontario Infection Control Resources Teams First Five Years ii

Disclaimer This document was developed by Public Health Ontario (PHO). PHO provides scientific and technical advice to Ontario s government, public health organizations and health care providers. PHO s work is guided by the current best available evidence. PHO assumes no responsibility for the results of the use of this document by anyone. This document may be reproduced without permission for non-commercial purposes only and provided that appropriate credit is given to Public Health Ontario. No changes and/or modifications may be made to this document without explicit written permission from Public Health Ontario. For further information Infection Control Resource Teams, Infection Prevention and Control (IPAC). Email: ipac@oahpp.ca Infection Control Resources Teams First Five Years iii

Contents Background... 1 Objective... 1 Methods... 2 Results... 3 Environmental services... 5 Antibiotic stewardship... 5 Program staffing and medical leadership... 6 Identification and isolation of CDI cases... 6 Hand hygiene... 6 Other notable areas in need of improvement... 7 Discussion and Conclusions... 7 Appendix A... 8 References... 11 Infection Control Resources Teams First Five Years iv

Background In response to several serious outbreaks of Clostridium difficile infection (CDI) that highlighted the need for heightened surveillance, Ontario amended regulations in 2008 to make Clostridium difficile associated disease (now more commonly referred to as CDI) outbreaks in public hospitals reportable to public health units under the Health Protection and Promotion Act. 1,2 At the same time, the Ministry of Health and Long Term Care created infection control resource teams (ICRTs) to provide support for hospitals and public health units as they worked together to manage and control CDI outbreaks. Originally, ICRTs were resourced via external contracts with academic health care centres, but they are now managed by staff in the Infection Prevention and Control (IPAC) department of Public Health Ontario. ICRTs are deployed following a request from the health care setting, the public health unit or both. The ICRT reviews the current status of the outbreak and provides recommendations for systemic improvements. The ICRT process involves the collection of detailed information about the outbreak, including epidemiological trends and control measures implemented to date. Each ICRT is typically led by at least one physician and includes IPAC professionals (ICPs) and epidemiologists with expertise in outbreak management and IPAC. Visits are usually completed in a single day, but have been expanded to multiple days in more complex outbreaks. Components of the visit include key informant interviews, data sharing and a tour of the facility site specifically the affected area(s). A verbal summary of the findings of the ICRT is presented at the end of the visit to allow urgent issues to be addressed immediately, and is followed a few weeks later by a more detailed written report. The Provincial Infectious Diseases Advisory Committee (PIDAC) Best Practice documents for IPAC are used as the basis for assessing practice and making recommendations. Objective We conducted a review of the reports from the first five years of CDI-related ICRT visits to summarize key areas of concern that were most frequently identified for practice improvement. In summarizing these recommendations, we hope to bring attention to the organizational factors and actions that all health care settings can undertake to improve IPAC practices and reduce rates of health care associated infections particularly CDI. Infection Control Resources Teams First Five Years 1

Methods We reviewed the following PIDAC Best Practice documents to identify specific recommendations that were important for CDI prevention and control: Best Practices for Infection Prevention and Control Programs in Ontario in All Health Care Settings (May 2012) 3 Routine Practices and Additional Precautions in All Health Care Settings (November 2012) 4 Annex A: Screening, Testing and Surveillance for Antibiotic-Resistant Organisms (AROs) in All Health Care Settings (February 2013) 5 Annex C: Testing, Surveillance and Management of Clostridium difficile in All Health Care Settings (January 2013) 6 Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings (May 2012) 7 Best Practices for Hand Hygiene in All Health Care Settings (April 2014) 8 The ICRT members identified 49 high-impact recommendations as being important for CDI prevention and control (see Appendix A). Each recommendation was categorized according to the following 14 areas of concern based on PIDAC best practices: 1. Environmental services 2. Antibiotic stewardship 3. Program staffing and medical leadership 4. Identification and isolation of CDI cases 5. Hand hygiene 6. Human waste management 7. IPAC education and training on Routine Practices/Additional Precautions 8. Audits of IPAC-related practices 9. Senior leadership support 10. Facility design 11. CDI outbreak management 12. Communication and partnerships 13. Access to appropriate and timely laboratory testing 14. Environmental cleaning services, policies and procedures for CDI We then carried out a retrospective review of all ICRT reports from 2008 to 2012 that had been prepared in response to a CDI outbreak or persistently high rates of CDI. We compared ICRT report findings with the 49 recommendations from the best practice documents and determined the facility status with respect to each recommendation. For each facility, we classified each recommendation as follows: Infection Control Resources Teams First Five Years 2

1. Consistent with best practice 2. Needs improvement 3. Does not meet best practice 4. Not addressed during the visit We also ranked each of the 14 areas of concern based on the total proportion of reports with at least one identified deficiency (i.e. needs improvement or does not meet best practice). For the purposes of this summary, we assumed that if a best practice recommendation was not addressed in the ICRT report, it was not an issue that required remediating action in that facility. A second reviewer validated all classifications. We performed a descriptive analysis of the data using Microsoft Excel. Results Between 2008 and 2012, 22 ICRT visits to 19 facilities were completed as a result of persistent high rates of CDI or outbreaks in Ontario hospitals. Three facilities had two ICRT visits over the five-year period. The majority (59%) of ICRT visits were at large community hospitals; the remainder were at acute teaching hospitals (27%) and small community hospitals (14%). There were several common issues identified by many of the ICRTs (see Table 1), resulting in similar recommendations across many of the reports. The top five areas of concern in which best practices were not met or needed improvement are shown in Table 1, ranked in general order of frequency and presented with the findings for each recommendation. Infection Control Resources Teams First Five Years 3

Table 1: Top five areas of concern in which best practices were not met or needed improvement Area of concern Environment al services Antibiotic stewardship Program staffing and medical leadership Identification and isolation of CDI cases Hand hygiene Recommendation Number (%) of reports in which best practices were not met or needed improvement (N=22) Process in place for cleaning of shared patient equipment 13 (59%) System for identification and storage of clean and dirty equipment 10 (45%) Adequate resources dedicated to environmental services to allow thorough and timely cleaning and disinfection; appropriate levels of supervisory staff Written policies and procedures with clear accountabilities and cleaning protocols 8 (36%) 7 (32%) Clarity around which product to use for routine/additional cleaning 4 (18%) Cleaning performed on a routine and consistent basis 3 (14%) Education program in place for new and experienced environmental services staff 3 (14%) Total reports with at least one identified deficiency 18 (82%) Resources dedicated to support antibiotic stewardship program 16 (73%) Antibiotic stewardship program in place 12 (55%) Total reports with at least one identified deficiency 16 (73%) Adequate number of ICPs and resources to implement the IPAC program (proportional to the size, complexity, case mix and estimated risk of the populations served by the facility) Infectious diseases/ipac physician support for the program or access to an external infectious diseases/ipac physician 14 (64%) 9 (41%) ICP(s)certified in IPAC (i.e. have their CIC) 3 (14%) Total reports with at least one identified deficiency 16 (73%) Patient transfer only when medically necessary 9 (41%) Appropriate initiation of Contact Precautions when there is a suspected or confirmed case of CDI Single-room accommodation with dedicated toileting facilities or commode chair 7 (32%) 6 (27%) Appropriate signage 4 (18%) Surveillance system to track the number of confirmed cases of CDI acquired in the facility 3 (14%) Adequate access to personal protective equipment 3 (14%) Dedicated patient care equipment 1 (5%) Total reports with at least one identified deficiency 16 (73%) Audit results shared with staff 10 (45%) Point-of-care alcohol-based hand rub 8 (36%) Total reports with at least one identified deficiency 15 (68%) Abbreviations: CDI, Clostridium difficile infection; CIC, certification in infection control; IPAC, infection prevention and control; ICP, infection prevention and control professional. Infection Control Resources Teams First Five Years 4

Environmental services Failure to implement environmental services recommendations was the most commonly identified issue in ICRT reports. The most frequently identified challenges in this area were processes for cleaning shared patient equipment, systems for separating clean and dirty equipment and adequate environmental services resources. In 59% of ICRT reports, processes for cleaning and disinfection of shared patient care equipment were identified as inadequate. Frequently, there was a lack of clearly defined responsibility for cleaning shared patient care equipment, leading to confusion about which equipment was clean, which was not, and who was responsible for cleaning it. Several hospitals had a system for marking equipment to identify that it had been cleaned, but awareness of and adherence to the system was not consistent. Overall, 45% of ICRT reports identified issues with the systems for identification and storage of clean and dirty equipment. In 36% of ICRT reports, management and staffing levels in environmental services were insufficient to ensure adequate cleaning of patient care areas and other key environments. Most hospitals were able to dedicate additional resources to environmental cleaning during outbreaks, but this was frequently at the expense of other areas and was not sustainable once the outbreak was over. The impact of patient flow on environmental services staff was often not recognized by other departments and was an important factor in the ability to provide effective and timely service. Lack of clarity about policies and procedures for cleaning protocols was identified in 32% of ICRT reports. Several hospitals had a variety of environmental cleaning products available that were intended for different uses (e.g. routine cleaning, isolation rooms) but staff members did not have adequate training or policies to assist them in distinguishing what product to use in a particular situation. For example, one hospital had one routine cleaning product and one sporicidal cleaning product but was unaware that these two products could negatively impact effectiveness when used together and could create an occupational health and safety hazard if accidentally combined. Antibiotic stewardship Comprehensive antibiotic stewardship programs (ASPs) have proven to be effective in reducing antibiotic use, 9 a known risk factor for the development of CDI. The recommendation for hospitals to have an ASP was added to Annex C of PIDAC s Routine Practices and Additional Precautions in All Health Care Settings document in 2012. 6 During the five-year review period, 73% of ICRT reports identified a lack of established ASPs with dedicated resources. The majority of hospitals were in the early stages of ASP implementation and did not have a dedicated pharmacy staff and/or physician. Without dedicated resources, ASP activities are not sustainable, likely limiting their success. 9 Infection Control Resources Teams First Five Years 5

Program staffing and medical leadership Sixty-four per cent of ICRT reports noted that hospitals had difficulty staffing their programs with ICPs to the recommended minimum levels. Some hospitals did not have a dedicated manager for the IPAC program, or combined the role with management of programs such as environmental services, occupational health and safety or central reprocessing. Infectious disease/ipac physician support was noted as insufficient in 41% of ICRT reports. This was particularly true for smaller hospitals, where access to infectious disease/ipac physician expertise was limited. Even when staffing was appropriate to the size and case mix of a hospital, it was common for the IPAC program to be responsible for roles outside the scope of IPAC, such as conducting audits for environmental services, selecting appropriate antibiotics or reviewing stool patterns to determine a CDI patient s progress. Assuming responsibility for other disciplines such as pharmacy or nursing detracts from time that can be dedicated to IPAC activities. The goal of the IPAC program should be to educate health care providers, give them the knowledge and tools to take ownership of their actions and ensure that IPAC best practices are followed in their daily activities. 3 Identification and isolation of CDI cases Unnecessary movement of patients was identified as an issue in 41% of ICRT reports. In one instance, patients experienced more than 10 moves during a hospitalization. This had an impact on the environmental services workload, created challenges in communication and made containment and management of the outbreak more difficult. Transferring patients with CDI to different units was a concern, as it was often done without adequate communication for the receiving unit to implement the measures necessary to prevent transmission of infection. Hand hygiene Just Clean Your Hands, an evidence based hand hygiene education and awareness program, was launched by the Ministry of Health and Long Term Care in 2008. 10 Many of the hospitals visited by ICRTs during the five-year study period were in various stages of implementing a hand hygiene program. Most facilities had installed alcohol based hand rub in patient care areas and at entry points, but it was identified as lacking or inadequate at point of care in 36% of ICRT reports. Point of care placement requires the positioning of alcohol-based hand rub in arm s reach of where care is being delivered. Hand hygiene audit results were not always shared with all staff and this was identified as an issue in 45% of ICRT reports. Audit data were typically provided to unit managers and senior management but not always distributed to the front line. There was often a general reluctance to provide individual feedback to staff during the audit process. Infection Control Resources Teams First Five Years 6

Other notable areas in need of improvement A number of human waste management practices were identified as not meeting best practice recommendations during various ICRT visits. Operational toilet taps and hand held spray wands for cleaning bedpans were flagged as an issue in 45% of ICRT reports; these items should not be used as they have the potential to spread C. difficile spores into the environment. 6 Several organizations had purchased washer/disinfectors or macerators for human waste management but had not trained staff properly on their use, or had not located them in appropriate places to encourage use. Inappropriate use of these human waste management systems often resulted in equipment being out of service, and staff often reverted to alternate options for disposal, increasing environmental contamination and the potential risk of transmission. Although almost all facilities had well established IPAC educational activities for staff orientation, ongoing continuing education was flagged as an issue in 45% of ICRT reports. IPAC staff would often rely on on thespot sessions in response to improper IPAC practices or outbreaks and did not deliver and/or evaluate regularly scheduled IPAC education sessions, which are necessary to reinforce IPAC knowledge and practices. Discussion and Conclusions ICRT visits provide a unique opportunity to observe first hand the state of IPAC in hospitals that are facing challenges in preventing and controlling CDI. These key findings will help inform hospitals and assist them in addressing gaps in current IPAC practices that may be contributing to the spread of CDI. This summary report may be used by facilities as evidence to support changes to IPAC programs, environmental services and other areas. The 49 high-impact recommendations have now been incorporated into the assessment carried out by the ICRT during visits to requesting facilities. The assessment of common findings from ICRT visits has helped inform Public Health Ontario s development of IPAC resources and has improved awareness of areas in which stakeholders may need support. For example, in 2008, ASPs were not included as a recommendation in Annex C Testing, Surveillance and Management of Clostridium difficile in All Health Care Settings. 6 ICRT visits revealed the fact that a large proportion of hospitals that were struggling to control CDI lacked ASPs or had insufficient resources dedicated to them; this finding provided the rationale for including ASPs in the 2012 revision to Annex C. Barriers and challenges related to ASP implementation encountered during ICRT visits have also helped inform the development of ASP tools and resources. Public Health Ontario will continue to review and summarize information collected from ICRT visits to help inform further improvements in current IPAC and related practices in the field. Infection Control Resources Teams First Five Years 7

Appendix A List of recommendations from PIDAC Best Practices that were not met or needed improvement Area of concern Environmental services Antibiotic stewardship Program staffing and medical leadership Identification and isolation of CDI cases Recommendation Number (%) of reports where PIDAC Best Practices were not met or needed improvement (N=22) Process in place for cleaning of shared patient equipment 13 (59%) System for identification and storage of clean and dirty equipment Adequate resources dedicated to environmental services to allow thorough and timely cleaning and disinfection; appropriate levels of supervisory staff Written policies and procedures with clear accountabilities and cleaning protocols Clarity around which product to use for routine/additional cleaning 10 (45%) 8 (36%) 7 (32%) 4 (18%) Cleaning performed on a routine and consistent basis 3 (14%) Education program in place for new and experienced environmental services staff 3 (14%) Total reports with at least one identified deficiency 18 (82%) Resources dedicated to support antibiotic stewardship program 16 (73%) Antibiotic stewardship program in place 12 (55%) Total reports with at least one identified deficiency 16 (73%) Adequate number of ICP(s) and resources to implement the IPAC program (proportional to the size, complexity, case mix and estimated risk of the populations served by the facility) Infectious disease/ipac physician support for the program or access to an external infectious disease/ipac physician 14 (64%) 9 (41%) ICP(s) certified in IPAC (i.e. have their CIC) 3 (14%) Total reports with at least one identified deficiency 16 (73%) Patient transfer only when medically necessary 9 (41%) Appropriate initiation of Contact Precautions when there is a suspected or confirmed case of CDI Single-room accommodation with dedicated toileting facilities or commode chair 7 (32%) 6 (27%) Appropriate signage 4 (18%) Surveillance system to track the number of confirmed cases of CDI acquired in the facility 3 (14%) Adequate access to personal protective equipment 3 (14%) Dedicated patient care equipment 1 (5%) Total reports with at least one identified deficiency 16 (73%) Infection Control Resources Teams First Five Year 8

Area of concern Hand hygiene Human waste management IPAC education and training on Routine Practices/Additio nal Precautions (RP/AP) Audits of IPAC related practices Senior leadership support Facility design CDI outbreak management Recommendation Number (%) of reports where PIDAC Best Practices were not met or needed improvement (N=22) Audit results shared with staff 10 (45%) Point-of-care alcohol-based hand rub 8 (36%) Total reports with at least one identified deficiency 15 (68%) Effective human waste management system in place (e.g. bedpan washer units, macerators for disposable waste products, hygie bags) 10 (45%) Bedpan cleaning wands or toilet taps not used 9 (41%) Toilet brushes/swabs used in CDI bathroom dedicated to that patient bathroom and discarded once Contact Precautions are discontinued Bedpans/commodes are cleaned/disinfected using a sporicide before use with another patient, or disposable bedpans are used 6 (27%) 2 (9%) Total reports with at least one identified deficiency 14 (64%) Routine ongoing front-line IPAC education 10 (45%) Orientation 3 (14%) IPAC actively participates in the planning and implementation of IPAC education (orientation, just-in-time education) 2 (9%) Total reports with at least one identified deficiency 12 (55%) Cleaning of shared patient equipment 8 (36%) Hand hygiene compliance 6 (27%) Environmental cleaning 4 (18%) Routine Practices/Additional Precautions through monitoring of proper use of personal protective equipment 4 (18%) Total reports with at least one identified deficiency 12 (55%) Multidisciplinary IPAC committee in place 5 (23%) The IPAC program is an organizational priority 2 (9%) Total reports with at least one identified deficiency 7 (32%) Surfaces, furnishings, equipment and finishes are smooth, nonporous, seamless and cleanable (e.g. no wood or cloth) 7 (32%) Total reports with at least one identified deficiency 7 (32%) Clear communication policies and procedures in place 4 (18%) Adequate numbers of staff with appropriate training to increase staffing capacity during outbreaks (e.g. geographically cohort nursing staff, additional environmental services) IPAC team has authority to implement outbreak measures up to and including closure of affected units Multidisciplinary outbreak management team established at initiation of outbreak 3 (14%) 1 (5%) 0 (0%) Infection Control Resources Teams First Five Year 9

Area of concern Communication and partnerships Access to appropriate and timely laboratory testing Environmental cleaning services, policies and procedures for CDI Recommendation Outbreak management team has authority to institute changes in practices or take other actions that are required to control the outbreak Number (%) of reports where PIDAC Best Practices were not met or needed improvement (N=22) 0 (0%) Total reports with at least one identified deficiency 7 (32%) Good communication between IPAC team and staff/departments 5 (23%) IPAC team has good partnership with environmental services 1 (5%) IPAC team has good partnership with occupational health and safety department 1 (5%) Total reports with at least one identified deficiency 6 (27%) CDI testing has a target turnaround time of less than 24 hours 4 (18%) CDI testing is available 7 days per week 3 (14%) Total reports with at least one identified deficiency 5 (23%) Twice-daily cleaning of patient room using hospital-grade disinfectant or sporicide Use of sporicide for cleaning of patient room on transfer/discharge or discontinuation of contact precautions. 2 (9%) 2 (9%) Daily cleaning of patient bathroom/commode with a sporicide 1 (5%) Double-clean room on patient discharge/transfer 0 (0%) Total reports with at least one identified deficiency 5 (23%) Abbreviations: CDI, Clostridium difficile infection; CIC, certification in infection control; IPAC, infection prevention and control; ICP, infection prevention and control professional. Infection Control Resources Teams First Five Year 10

References 1. Specification of Reportable Diseases, O. Reg. 559/91. Available from: http://www.ontario.ca/laws/regulation/910559 2. Specification of Communicable Diseases, O. Reg. 558/91. Available from: http://www.ontario.ca/laws/regulation/910558 3. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Best practices for infection prevention and control programs in Ontario in all health care settings. 3rd edition. Toronto, ON: Queen s Printer for Ontario; May 2012. Available from: http://www.publichealthontario.ca/en/erepository/bp_ipac_ontario_hcsettings_2012.pdf 4. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Routine practices and additional precautions in all health care settings. 3rd edition. Toronto, ON: Queen s Printer for Ontario; November 2012. Available from: https://www.publichealthontario.ca/en/erepository/rpap_all_healthcare_settings_eng2012.pdf 5. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex A: Screening, testing and surveillance for antibiotic-resistant organisms (AROs). Annex to: Routine practices and additional precautions in all health care Settings. Toronto, ON: Queen s Printer for Ontario; February 2013. Available from: https://www.publichealthontario.ca/en/erepository/pidac- IPC_Annex_A_Screening_Testing_Surveillance_AROs_2013.pdf 6. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex C: Testing, surveillance and management of Clostridium difficile in all health care settings Annex to: Routine practices and additional precautions in all health care settings. Toronto, ON: Queen s Printer for Ontario; January 2013. Available from: https://www.publichealthontario.ca/en/erepository/pidac- IPC_Annex_C_Testing_SurveillanceManage_C_difficile_2013.pdf 7. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Best practices for environmental cleaning for prevention and control of infections in all health care settings. 2nd edition. Toronto, ON: Queen s Printer for Ontario; May 2012. Available from: https://www.publichealthontario.ca/en/erepository/best_practices_environmental_cleaning_2012.pdf 8. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Best practices for hand hygiene in all health care settings. 4th edition. Toronto, ON: Queen s Printer for Ontario; April 2014. Available from: http://www.publichealthontario.ca/en/erepository/2010-12%20bp%20hand%20hygiene.pdf 9. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP et al, Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Guidelines for developing an institutional program to enhance antibiotic stewardship. Clin Infect Dis. 2007:44(20):159 77. 10. Public Health Ontario. Just clean your hands (JCYH) [Internet]. Toronto, ON: Public Health Ontario; 2015 [cited 2015 Nov 24]. Available from: http://www.publichealthontario.ca/en/browsebytopic/infectiousdiseases/justcleanyourhands/pages/ Just-Clean-Your-Hands.aspx Infection Control Resources Teams First Five Year 11

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