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ANNUAL REPORT

2011 – 2012

Provincial Health Services Authority includes:

PHSA INFECTION PREVENTION & CONTROL (IPAC) SERVICE

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Executive Summary............................................................................................................................................................3

Executive Summary of Key HAI Indicators ............................................................................................................5

Introduction to PHSA Infection Prevention and Control (IPAC) Service ................................................6

Organizational chart ........................................................................................................................................................9

Team members..................................................................................................................................................................10

Stop the Spread – A PHSA Hand Hygiene (HH) Program ............................................................................12

Hand Hygiene (HH) Compliance Rates .................................................................................................................13

Outbreak Management.................................................................................................................................................17

Education..............................................................................................................................................................................17

PHSA Reprocessing Practices Report ....................................................................................................................19

Clostridium difficile infections (CDI) incidence rate ....................................................................................22

Methicillin-resistant staphylococcus aureus (MRSA) incidencrate...................................................25

Vancomycin-resistant Enterococci (VRE) incidence rate ..........................................................................27

BC Cancer Agency Catheter-related Blood Stream Infections ................................................................29

BC Children’s Hospital (BCCH) NICU and PICU: Catheter-related Blood Stream Infection…….29

BC Children's Hospital (BCCH) inpatients: healthcare-associated surgical site infections….30

BC Women’s hospital: (BCW) ha-surgical site infections – caesarean sections………………..…..31

Appendix: Surveillance Definitions ........................................................................................................................33

TABLE OF CONTENTS

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This fiscal year, we have focused on streamlining data collection and management, as reporting demands from various stakeholders has increased substantially. We provide quarterly data on hand hygiene (HH) compliance, health care associated Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE), C difficile infection (CDI) and catheter related blood stream infections (CRBSI). We send data to PHSA leadership, infection control committees, quality management, Provincial Infection Control Network (PICNet) and The Canadian Nosocomial Infection Surveillance Program (CNISP). HH compliance is posted in public areas on each unit. Surgical site infections from the BCCH are now reported through the National Surgical Quality Improvement Program (NSQIP).

1. Site specific surveillance

BC Cancer Agency (BCCA): The overall HH compliance at BCCA was 80%. There were no healthcare-associated (HA) VRE or HA-MRSA cases at the inpatient unit and there were 4 HA-CDI cases.

BC Women’s Hospital (BCW): The overall HH compliance was 75%. There were 10 HA-MRSA cases, no HA-VRE cases and no identified HA-CDI.

BCCH: The overall HH compliance was 80%. There were 7 HA-MRSA and 4 HA-VRE cases. There were 37 HA-CDI representing a rate of 0.77cases /1000 patient days. This represents an increase from 2010/2011. This may partly be explained by the fact that 70% (25/37) of CDI cases were from high risk oncology patients. In addition, the increased rate may have been impacted by the introduction of a highly sensitive laboratory test in November, 2011.

BC Mental Health and Addiction Services (BCMHAS): The overall HH compliance was 94 %. BC Centre for Disease Control (BCCDC): The overall HH compliance was 84%.

2. HH compliance The PHSA IPAC service has had a busy year evaluating and improving our HH program, Stop the Spread. Regular HH compliance audits were performed at all sites and results posted on each unit. The PHSA overall HH compliance was 80% during this fiscal year. Many new social marketing tools and strategies were launched. Examples include “Its’ OK to ask” posters, lanyards, banners and a HH video. Education sessions have occurred throughout the organization. PHSA IPAC service representatives sit on the Provincial HH working group with the aim to standardize HH practices across the province.

EXECUTIVE SUMMARY

From top: BC Cancer Agency, BC Women’s Hospital, BC Children’s Hospital, BC Mental Health &

Addiction Services, BC Center for Disease Control.

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3. PHSA Reprocessing practices The Ministry of Health (MOH) mandated yearly reprocessing audits of critical and semi-critical items were concluded with a total of 97% compliance.

4. General Other major projects this fiscal year were the development of IPAC guidelines/standards including guidelines for BCCH and BCW redevelopment project, review and update of the BCCH and BCW infection control manual and guidelines for patient with cystic fibrosis (CF). In addition, a significant amount of time was spent on preparatory work for the June 2012 BCCH Accreditation. At the BCCA, the IPAC service devoted time for the planning for the Centre for the North. We thank Georgene Miller, Corporate Director of Medical Affairs and Quality and Risk Management, for her leadership and support. Eva Thomas, M.D, PhD, FRCP(C) Medical Microbiologist Corporate Director, PHSA Infection Prevention and Control Service Ghada Al-Rawahi, M.D., FRCP(C) Medical Microbiologist Infection Control Officer, BCCA

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*PHSA CDI rates are mainly impacted by the

high proportion of oncology patients. Healthcare-associated cases represent patients with CDI that occurred more than 3 days after admission rather than patient-to-patient transmission. Although the clinical target should be zero, the target of 8 is based on the PHSA experience of CDI in a highly vulnerable patient population

The PHSA Infection Prevention and Control (IPAC) service is responsible for IPAC in all PHSA sites and reports to the VP of Quality, Safety and Outcome Improvement. The PHSA IPAC service collaborates with other health authorities, Provincial Infection Control Network of B.C. (PICNet) and regional Public Health services to support best practices, standardization of guidelines and surveillance activities.

1 Status = achieving target, = does not meet target, but improving with (steady trend arrow), = not improving and is deteriorating (steady or deteriorating arrow)

2 Trend = improving; at least 4 consecutive data points moving towards target, = deteriorating; at least 4 consecutive data points moving away from target, = steady; fewer than 4 consecutive data points moving in either direction

EXECUTIVE SUMMARY OF KEY HAI INDICATORS

Indicator Status1 Trend2 Target

HH Compliance Rate 100%

Clostridium difficile Infection (CDI) Incidence Rate BCCA

8*

Clostridium difficile Infection (CDI) Incidence Rate BCCH and BCW

Methicillin-resistant Staphylococcus aureus (MRSA) Incidence Rate BCCA

0%

Methicillin-resistant Staphylococcus aureus (MRSA) Incidence Rate BCCH and BCW

Vancomycin-Resistant Enterococci (VRE) Incidence Rate BCCA

0%

Vancomycin-Resistant Enterococci (VRE)

Incidence Rate BCCH and BCW

INTRODUCTION TO PHSA INFECTION PREVENTION AND CONTROL

(IPAC) SERVICE

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PHSA IPAC Service mission and vision are aligned with those of PHSA.

The PHSA IPAC Service aims to improve patient safety through the following:

Outbreak management

The PHSA IPAC Service is responsible for investigating clusters of infections or outbreaks. This is done in close collaboration with Public Health and the BC Centre for Disease Control (BCCDC).

Surveillance

Standardized, regular monitoring of healthcare-associated infections (HAI) is essential to reduce the risk of disease transmission in the hospital.

Monitoring occurs through:

1. Case identification at ward rounds.

2. Case identification through receiving daily Microbiology significant reports.

3. Detection and management of outbreaks.

4. Monitoring trends in transmission of organisms and intervening when spread is detected.

5. Interpreting surveillance data within the appropriate clinical context.

6. Determining disease burden in all PHSA institutions.

7. Continuously evaluating and improving interventions.

8. Continuing improvement of surveillance systems by standardization of definitions and implementation of data quality control and assurance procedures.

9. Revision and standardization of regular reporting structures and formats.

Goal: To create a culture of patient safety in all PHSA agencies by eliminating the risk of acquiring and transmitting healthcare-associated infections.

Objective:

To reduce the risk of healthcare-associated infections by providing comprehensive infection prevention and control advice in a constructive and collaborative manner. This is achieved by promoting an interdisciplinary, authority wide program where best practice infection prevention and control guidelines are integrated into all aspects of patient care.

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Education The PHSA IPAC Service is constantly assessing, developing and revising strategies to meet the learning needs of staff in relation to best practices for infection prevention and control. This is provided through staff orientation, ongoing consultation, agency-specific IPAC Manuals and other modalities based on staff learning needs.

IPAC Standards The PHSA IPAC Service ensures that IPAC standards are in place and reviewed and updated regularly in collaboration with different areas.

Construction The PHSA IPAC Service is actively participating in IPAC issues relating to all construction and renovations to ensure that IPAC standards are considered and adhered to. The PHSA IPAC Service has representation on the Lower Mainland Facilities Management Infection Control Committee (LMFMICC).

Reprocessing of Medical Devices The PHSA IPAC Service is in the unique position to have a full reprocessing manager who oversees sterile processing across all PHSA agencies.

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Dr. Eva Thomas

Corporate Director, PIPCS

PHSA

Robyn Hunter

Infection Control Coordinator

PHSA

Dr. Ghada Al Rawahi

Microbiologist,

IC Officer BCCA

Andrea McQuilling

IC Practitioner

Riverview

Ron Morley

IC Practitioner

Forensic

Iona Joseph

IC Practitioner

Riverview Alison Chant

IC Practitioner

BC Cancer - VCC

Bonnie Anderson

IC Practitioner

C & W Laurel Nicholson

IC Practitioner

BC Cancer - AC

Kelsi Laporte

IC Practitioner

C & W

PHSA Infection Prevention

and Control (IPAC) Service

Georgene Miller

VP, Quality Safety & Outcome Improvement

PHSA

Jun Chen Collet

Epidemiologist

PHSA

Dr. Rusung Tan

Microbiologist

Dr. G. Al Rawahi

Microbiologist

Dr. Eva Thomas

Microbiologist

Dr. Simon Dobson

Infectious Disease

PHSA Infection

Prevention & Control

Officer

Rotating Coverage &

After Hours Call Group

604-875-2161

Facility Infection Control Committees

& Facility Administration

Dr. Peter Tilley

Microbiologist

Lynda Cranston

Chief Executive Officer

PHSA

Louise Holmes

Coordinator

C & W

Karen Mok

Hand Hygiene Auditor

PHSA

Viola Tang

Manager, IC & Re-Processing

PHSA

Kimberley PeelIC Practitioner

BC Cancer – VC/FVC

Marney Hunt

IC Practitioner

C & W

Judy Tearoe

IC Practitioner

BC Cancer - CSI

Dr. Simon Dobson

Head, Infectious & Immuno Diseases

Kristie Harding

IC Practitioner

BC Cancer - VIC

Brad Procyshyn

Hand Hygiene Auditor

PHSA

Kavindya Peiris

Hand Hygiene Auditor

PHSA

Brenda Ryder

IC Practitioner

BC Cancer - CN

ORGANIZATIONAL CHART

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Leadership Vice President, Quality Safety and Outcome Improvement Georgene Miller

PHSA Infection Prevention and Control (IPAC) Service Program Director Eva Thomas, MD, PhD Associate Director Simon Dobson, MD

BCCA Infection Control Officer Ghada Al-Rawahi, MD (0.5 FTE)

On-call medical infection control coverage Peter Tilley, MD (Medical Microbiology) Rusung Tan, MD, PhD (Medical Microbiology) Eva Thomas, MD (Medical Microbiology) Ghada Al-Rawahi, MD (Medical Microbiology) Simon Dobson, MD (Pediatric Infectious Disease)

Infection Control Practitioners Coordinators Robyn Hunter, PHSA IC Coordinator (1FTE) Louise Holmes, C&W IC Coordinator) (1 FTE)

BCCH & BCW Bonnie Anderson (1 FTE) Vacant (0.6 FTE) Marney Hunt (0.83 FTE)

BCCA Alison Chant (1 FTE) Kimberly Peel (1FTE) Laurel Nicholson (0.4FTE) Kristie Harding (0.5 FTE) Judy Tearoe (0.5 FTE)

Riverview

Ron Morley (1 FTE) Iona Joseph (0.5FTE) Andrea McQuilling (0.5FTE)

TEAM MEMBERS

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PHSA Infection Control Epidemiologist Jun Chen Collet (1 FTE)

PHSA Infection Prevention and Control Reprocessing Manager Viola Tang (1 FTE)

PHSA HH Auditors, Student Co-op Program Maja Horgas Karen Mok Kavindya Peiris Brad Procyshyn

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Background Healthcare-associated infections (HAIs) cause 8,000 to 12,000 deaths in Canada each year. HAIs are most frequently spread via transiently contaminated hands. The best way to prevent such transmission is strict adherence to HH. Surprisingly, poor HH is still common in health care settings worldwide.

The PHSA HH program is adapted from the Canadian Patient Safety Institute, which is the same program that Safer Health Care Now uses. They are all based on the WHO’s Global Patient Safety Challenge" Clean Care is Safer Care" that was launched in 2005. The main difference is that most of Canada (including PHSA) uses 4 moments of HH, having combined after patient and after environment contact. HH compliance is measured using an audit tool, modified from the CPSI.

PHSA is posting its HH compliance rates as percentages for specific observation time periods using the following formula:

Number of HH events (includes rub and wash) X 100 Number of HH opportunities

STOP THE SPREAD – A PHSA HAND HYGIENE (HH) PROGRAM

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Figures 1-4 illustrate 2011-2012 PHSA HH Compliance In summary:

Overall, HH compliance has increased from 40% in 2008/09 to 80% in Q2 2012/13. By Quarter 3, 2011/2012, the provincial target of 80% had been met. (Figure 1).

There has been overall improvement of HH compliance by both “before patient” contact and “after patient” contact, although the HH compliance for HH “after patient” contact was still higher than “before patient” contact (82% vs.75% for 2011/12). (Figure 2).

Comparing two fiscal year data (2010/2011 vs. 2011/12), there is an overall improvement in all Healthcare provider (HCP) groups (Figure 3).

Figure 4 illustrates Institution specific overall HH Compliance

Figure 1: PHSA Overall HH by Fiscal year and Quarter

Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2008/09 2009/10 2010/11 2011/12 2012/13

Provincial Target for 2011/12 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

Percent compliance 43% 49% 58% 62% 67% 54% 70% 61% 58% 67% 75% 76% 70% 82% 80% 81% 82%

Total Opportunities 1209 3139 1433 1335 1274 1278 718 723 236 886 1469 1350 1416 1948 3384 1672 871

Number Compliant 520 1549 826 822 849 688 502 444 138 596 1097 1026 995 1605 2723 1346 711

0%

20%

40%

60%

80%

100%

The Trend of HH Compliance at PHSA2008-2012

Figure 2: PHSA Overall HH Compliance by HH Moment

60%

77%75%82%

0%

20%

40%

60%

80%

100%

Before Patient Contact After Patient Contact

HH Compliance by Moment

2010/11 compliance 2011/12 compliance

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Figure 3: PHSA Overall HH Compliance by Healthcare Provider (HCP) Group

73%

59% 61%68%

81%70%

76% 73%

0%

20%

40%

60%

80%

100%

Nursing Staff Physicians Clinical Support Services

Other

HH Compliance by HCP Group

2010/11 compliance 2011/12 compliance

Figure 4: Institution specific overall HH Compliance

Facility

2011/12 HH Compliance %

2011 2012

Apr - Jun Jul -Sep Oct -Dec Jan - Mar

BCCH 77% 73% 81% 80%

Sunny Hill Health Center for Children (SHHCC) 82% - 90% -

BCMHAS– BCCH Site 81% - 89% -

BCW 70% 68% 72% 75%

BCCA –Abbotsford Center - NA - 88%

BCCA - Fraser Valley Center - NA - 72%

BCCA – Kelowna Center - NA - 87%

BCCA – Vancouver Center 80% 69% 81% 80%

BCCA – Victoria Center - NA - 81%

BCCDC - New Westminster - NA - 81%

BCCDC - Vancouver - NA - 88%

BCMHAS – Forensics NA - 96% -

BCMHAS – Riverview NA - 91% - - : No HH observation done for that period. NA: Data not available

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Major HH activities this fiscal year included:

Regular HH audits across all PHSA sites. New sites/departments were added to the audit process including BCMHAS -- BCCH site,

outpatient departments (Renal Dialysis Unit and oncology clinic). Celebration of World HH Day in May at all sites (timing different at BCCDC due to accreditation)-

using stickers, posters, banners, roving carts, prizes, games. Celebration National Infection Control Week in October. Regular in-services, orientation.

Regular updates of the BCCH Intranet HH team site. “It’s okay to ask” posters put in all patient rooms, exam rooms at BCCH and BCW.

Launched HH Dance Video. Distributed HH lanyards with Stop the Spread Wash your hands- PHSA wide. Purchased HH Banners for all sites and prominently displaying those during the national IC week

and World HH Day.

Updated Life Size Posters to include Santa, Sunny Bear, families, and pregnant women. Installed and reviewied the location of alcohol based hand rub dispensers.

Prior to the closing of Riverview Hospital, the following projects were initiated to improve staff HH compliance at a challenging period of uncertainty and change. Project planning began in the summer following the May 2011 HH audit and included:

Snapshot audits by ICPs with immediate feedback on the use of the 4 Moments

Posters illustrating the message, “gloves are not enough” Lanyard tags of “The 4 Moments for HH” were distributed Discussion sessions were held and information memos were sent to clinical leaders Education sessions were given by ICPs and Nurse Clinicians were attended by 178 direct

care staff. This initiative resulted in an overall HH compliance result of 90.7% for the November 2011

HH audit. This was an improvement of 35% from the May 2011 HH audit results.

There was one outbreak identified throughout PHSA facilities. It was at Riverview Hospital. A number of interventions were introduced and the outbreak was declared over after 11 days. No other outbreaks

were identified at any of the PHSA sites.

Date Length Type Organism Patient #

Staff #

Site

April 2011 11 days Respiratory RSV 6 2 Riverview

OUTBREAK MANAGEMENT

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Staff education is a major component in the role of the Infection Control Practitioner (ICPs) at all PHSA sites. HH educational sessions were held at all sites. The ICPs continue to deliver IC education sessions during general orientation at all sites. The Infection Prevention and Control Services team is constantly assessing, developing and revising strategies to meet the learning needs of the staff in relation to best practices for infection control. IPAC educational sessions conducted during the fiscal year included topics such as:

Antibiotic resistant organisms

HH IC Manual Launch

Influenza Outbreak Prevention Shingles

Tuberculosis Routine Practices and Additional Precautions

Members of the PHSA IPAC Service regularly attend educational sessions/teleclasses, Infectious Diseases/Medical Microbiology rounds and Oncology rounds. They also attend educational days (PICNet, CHICA-BC), CSA seminars, workshops and national and international conferences to expand our knowledge and keep current with best practices of infection control.

Medical Device Reprocessing Audits The Ministry of Health (MOH) audit of medical device reprocessing is designed to improve patient

safety through adoption of best practices for cleaning, disinfection and sterilization of medical devices.

The policy applies to all single use and multiple use devices and patient care equipment used within health authority facilities and programs.

The original audit for PHSA was done in 2007, with subsequent audits conducted in 2009 2010 and 2011.

The PHSA audit tool is adapted from the MOH.

Major sterile processing activities for the fiscal year include:

Completing the fourth MOH mandated reprocessing audit.

EDUCATION

PHSA REPROCESSING PRACTICES REPORT PREPARED BY VIOLA TANG, PHSA INFECTION PREVENTION AND CONTROL REPROCESSING

MANAGER

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Reviewing appropriate location for reprocessing of flexible scopes. Reprocessing of Ear Nose and Throat (ENT) flexible scopes are now being reprocessed by Certified

Sterile Processing Technicians. Reprocessing of flexible scopes, laryngoscope blades are now performed by Certified Sterile

Processing Technicians. An increase of flexible scopes and laryngoscope blades inventory in PICU Completing the review of the current reusable medical devices reprocessing activities at BCCA,

Vancouver Island centre – Radiation Therapy Department. Reprocessing of reusable medical devices was moved to Royal Jubilee Hospital (RJH) Sterile

Processing Department.

Medical Device Reprocessing Compliance The audits in 2010 and 2011 have shown that overall compliance is improving across all areas, reaching 97-100% at all PHSA Sterile Processing sites.

Section Audit Section Description 2007 2009 2010 2011

1 Single use items 96% 90% 100% 100%

2 Reusable items N/A 100% 100% 100%

3 Indications sterilization or High Level Disinfection (HLD) 98% 95% 100% 100%

4 General 59% 84% 95% 97%

4a Detergents N/A 65% 93% 99%

4b Medical device and equipment N/A 90% 95% 97%

5 Cleaning 78% 79% 96% 99%

6 Chemical HLD, no endoscopes 58% 69% 92% 99%

6a Documentation (Chemical HLD, no endoscopes) N/A 19% 89% 95%

7 Pasteurization 97% 100% 100% 100%

8 Sterilization 74% 91% 98% 95%

8a Flash sterilization 59% 80% 88% N/A

8b Steris System 1 98% 97% 96% 99%

9 Purchasing & reprocessing instruction 53% 98% 100% 100%

10 Education 67% 55% 90% 99%

11 Home care N/A N/A N/A N/A

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Note: N/A indicates that this activity is not performed anymore.

CDI Incidence Rate

Status

Trend

Target 100%

HAI Status

HAI Trend

HAI Target

Clostridium difficile Infection (CDI) Incidence Rate BCCA 8*

Clostridium difficile Infection (CDI) Incidence Rate BCCH and BCW

*PHSA CDI rates are mainly impacted by the high proportion of oncology patients. Healthcare-associated cases represent patients with CDI that occurred more than 3 days after admission rather than patient-to-patient transmission. Although the clinical target should be zero, the target of 8 is based on the PHSA experience of CDI in a highly vulnerable patient population.

Background Clostridium difficile is the leading cause of healthcare-associated diarrhea and is associated with significant morbidity and mortality. Over the past decade, there was an increase in the incidence and severity of C. difficile infection (CDI) related to the emergence of a hypervirulent C. difficile strain. Risk factors for CDI include antibiotic usage, hospitalization, malignancy and co-morbidities e.g. inflammatory bowel disease.

12 Dental clinic N/A 68% 100% 100%

13 HLD flexible endoscope 83% 85% 92% 100%

13a HLD flexible endoscope – cleaning 97% 85% 98% 98%

13b HLD manual disinfection 59% 70% N/A N/A

13c HLD automated disinfection 90% 97% 100% 100%

13d Endoscopes storage 54% 53% 73% 98%

13e Documentation (HLD flexible endoscope) 76% 56% 96% 98%

Total PHSA compliance 69% 76% 94% 97%

CLOSTRIDIUM DIFFICILE INFECTIONS (CDI)

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BCCA Inpatient Unit (Vancouver Centre) CDI (Total) During the 2011-2012 fiscal year, a total of 7 patients were admitted with CDI.

Healthcare-associated (HA) CDI (BCCA-Onset) During the 2011-2012 fiscal year, 4 patients had HA-CDI with an overall rate of 5.7 per 1,000 patient days. Of these 4 patients, 50 % were male and the underlying malignancy included lymphoma (2), breast (1) and gastric (1) cancers.

HA-CDI trend over past 3 fiscal years The rate spike in the 2009-2010 fiscal year was associated with a cluster of CDI cases. A number of interventions were implemented and rates decreased by more than 50% and have remained stable.

BCCH and BCW CDI (Total) During the 2011-2012 fiscal year, a total of 52 patients were admitted with CDI.

HealthCare-Associated (HA) CDI During the 2011-2012 fiscal year, 35 (67%) patients had HA-CDI with an overall rate of 0.73 per 1,000 patient days (95% CI: 0.53-1.02). This represents an increase from 2010/2011. This may partly be explained by the fact that 69% (24/35) of CDI cases were from high risk oncology patients. In addition, the increased rate may have been impacted by the introduction of a highly sensitive laboratory test in November, 2011. We continue to review potential contributing factors in relation to CDI.

HA-CDI Trend-BCCA

4 Cases 4 Cases

10 Cases

0

4

8

12

16

Rate/1,000 Patient Days

Rate 13.4 5.3 5.7

2009-2010 2010-2011 2011-2012

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Figure 1: Rate of healthcare-associated CDI cases at BCCH & BCW

Note:

1. Patients in psychiatric beds or less than one year of age were excluded in the calculation of patient days. 2. Starting April 2010, HA-CDI case definition used at C&W has been changed. Unlike the old definition, CDI cases that

were discharged within 4-8 weeks prior to CDI onset are not considered as HA-CDI according to the new definition. This may contribute to the declining rate in year 2010/11 (See Figure 1).

MRSA Incidence Rate

HAI Status

HAI Trend

HAI Target

Methicillin-resistant Staphylococcus aureus (MRSA) Incidence Rate BCCA

0%

Methicillin-resistant Staphylococcus aureus (MRSA) Incidence Rate BCCH and BCW

Background MRSA is an antibiotic resistant bacterium that can be transmitted in health care settings. This may result in colonization of patients or true infection.

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

# of HA-CDI cases 26 14 21 19 32 19 35

Patient days 50580 52240 51572 49650 44140 48956 47814

Rate per 1000 patient days 0.51 0.27 0.41 0.38 0.72 0.39 0.73

0.0

0.5

1.0

1.5

2.0

2.5

3.0

HA-CDI cases/ 1000 patient days

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)

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BCCA Inpatient Unit (Vancouver Centre) MRSA (Total) A total of 10 newly identified MRSA cases were admitted to the inpatient unit. All 10 cases were identified through admission screening as colonization cases. HA-MRSA (BCCA-onset) During the 2011-2012 fiscal year, there were no HA-MRSA cases

HA-MRSA (BCCA-onset) trend over past 3 fiscal years Over the past 3 fiscal years, there were no cases of HA-MRSA. With respect to cases identified on admission screening there have been no cases that were solely admitted to BCCA-VC in the previous 12 months.

BCCH and BCW MRSA (Total) A total of 58 newly identified MRSA patients were admitted to C&W.

HA-MRSA

During the 2011-2012 fiscal year, there were 17/58 (29%) HA-MRSA cases, corresponding to an overall incidence rate of 0.19 /1000 patient days.

HA-MRSA trend

Figure 2: Rate of healthcare-associated new MRSA cases at C&W

Note: Patients in psychiatric beds were excluded in the calculation of in-patient days.

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

# of HA-MRSA new cases 18 23 19 6 16 17

Patient days 95729 95344 88383 88491 90719 89662

Rate per 1000 patient days 0.19 0.24 0.21 0.07 0.18 0.19

0.0

0.2

0.4

0.6

0.8

HA-MRSA new cases / 1000 patient days

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VRE Incidence Rate

HAI Status

HAI Trend

HAI Target

Vancomycin-Resistant Enterococci (VRE) Incidence Rate BCCA

0% Vancomycin-Resistant Enterococci (VRE) Incidence

Rate BCCH and BCW

Background VRE refers to strains of enterococci that are resistant to vancomycin, making them difficult to treat. This may result in colonization of patients or true infection.

BCCA Impatient Unit (Vancouver Centre) VRE (Total) A total of 7 newly identified VRE cases were admitted to the inpatient unit. All cases were identified through admission screening.

HA-VRE (BCCA-onset) During the 2011-2012 fiscal year, there were no HA-VRE cases

HA-VRE (BCCA-onset) trend over past 3 fiscal years HA-VRE colonization has remained steadily low over the past 3 fiscal years.

VANCOMYCIN-RESISTANT ENTEROCOCCI (VRE) INCIDENCE RATE

HA-VRE (BCCA Onset) Trend

1 Case 1 Case

0

0.2

0.4

0.6

0.8

1

Rate/1,000 Patient days

Rate 0.1 0.1 0

2009-2010 2010-2011 2011-2012

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BCCH and BCW

VRE (Total) A total of 4 newly identified VRE cases were admitted to C&W.

HA-VRE During the 2011-2012 fiscal year, there were 4 HA-VRE cases, corresponding to an incidence rate of 0.04 cases/1000 patient days.

CATHETER-RELATED BLOOD STREAM INFECTION (CRBSI) Background PHSA agencies deliver highly specialized care in high risk areas such as oncology, neonatal and pediatric intensive care units. Many of the patients in these units have central venous catheters and therefore, surveillance of Catheter-Related Blood Stream Infection (CRBSI) is a pivotal component of PHSA IPAC activities.

BCCA Impatient Unit (Vancouver Centre) In order to collect meaningful data for catheter-related blood stream infection, a denominator represented by Central-Venous Catheter (CVC) days was essential. This was achieved in September 2011 by collaborating with the staff at the BCCA inpatient unit. Over the last 7 months (September 1, 2011 to March 31, 2012), there were 4 blood stream infections in patients with central lines. One case was classified as potentially catheter-related with an overall rate of 1.5 per 1,000 CVC days. The CR-BSI case had an underlying metastatic colorectal cancer and Klebsiella pneumoniae bacteremia in a port-o-cath type device. Although the data was collected over 7 month period, it will be useful as a baseline for future rates.

BCCH and BCW CRBSI: NICU In 2011/12, 1 CRBSI case was identified at the paediatric intensive care unit (PICU), corresponding to an incidence rate of 0.5 case/1000 catheter days. This rate is well below the rate published by National Health and Safety Network (NHSN) for paediatric ICU (6.6/1000 CVC days in 2002-2004).

Figure 1. CRBSI Trend (PICU)

2009/10 2010/11 2011/12

# of cases 7 2 1

Catheter - days 2889 1802 2050

CLABSI cases/1000 catheter days

2.4 1.1 0.5

0.0

2.0

4.0

6.0

8.0

10.0

CRBSI cases / 1000 Catheter days

PICU at BC Children's Hospital

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CRBSI: PICU In 2011/12, 21 CRBSI cases were identified at the neonatal intensive care unit (NICU), corresponding to an incidence rate of 4.8 case/1000 catheter days. The rate has increased compared to previous years, but the increase is not statistically significant (P= 0.26). This rate is comparable to the rates published by National Health and Safety Network (NHSN) for neonatal ICU in 2002-2004 which ranged from 3.5 to 9.1/1000 CVC days according to birth weight group.

Figure 2. CR-BSI Trend (NICU)

2008/09 2009/10 2010/11 2011/12

# of cases 28 15 14 21

Catheter - days 4153 5000 4296 4350

CLABSI cases/1000 catheter days 6.7 3.0 3.3 4.8

0.0

2.0

4.0

6.0

8.0

10.0

CRBSI cases / 1000 Catheter days

NICU at BC Women's Hospital

Background Infection after surgery can lead to serious complications including prolonged hospitalization, increase patient anxiety and overall health care costs. Therefore, SSI surveillance has become a universal measure of quality in surgical programs and is a required organizational practice by Accreditation Canada. Until recently, and due to resource constraints, surgical site infection surveillance at BCCH focused on in -patient surveillance only with no post discharge SSI data collection.

In July 2011, the Department of Surgery at BCCH joined the U.S based National Surgical Quality Improvement Program (NSQIP) and begun conducting a SSI surveillance including post discharge follow-up. This was implemented for selected procedures only. This surveillance method used by NSQIP has significantly improved the overall SSI case finding by incorporating post-discharge surveillance. It also enabled to benchmark BCCH performance with other institutions (mostly in US) who participate in NSQIP.

To avoid the duplication of surveillance efforts, the PHSA IPAC Service has been working with the Department of Surgery and the NSQIP team to identify appropriate IPAC surgical site surveillance initiatives. As cardiac surgeries are not part of the NSQIP program, the IPAC Service is in the process of exploring an SSI surveillance system for these surgeries.

BCCH INPATIENTS: HEALTHCARE-ASSOCIATED SURGICAL SITE

INFECTIONS (HASSI)

24

Over 2000 Caesarean Section (C-section) procedures are performed at BCWH annually. Until 2010, C-section surveillance at PHSA was restricted to patients who developed SSI during their post-operation hospital stay or who were readmitted as a result of SSI.

Since 2010, the IPAC team has been working with Providence Health Care (PHC) to develop standardized definitions, surveillance tools and SSI case finding methods for C-section. In November, 2011, PHSA IPAC conducted a pilot study to test the practicality of these tools and assess the impact of a new SSI surveillance system. The case finding method included improved in-patient surveillance, where daily rounds were conducted as well as a post-discharge chart review at 30 days.

An increase in SSI cases was detected during the 5 month study period (November 2011 to March 2012). We identified fourteen cases that developed SSI during the study period. Thirteen of thoses developed SSI post discharge. The PHSA IPAC Service continues to collaborate with the Department of Obstetrics and Gynaecology and PHC to develop a valid and sustainable surveillance system for SSI following C-section.

Figure 1. BCW C-section SSI Rate (Pilot Study)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2011 2012

# of SSI cases 0 0 0 0 0 0 1 1 2 5 3 2

# of C-section procedures 175 151 178 175 185 198 158 185 160 168 155 173

SSI Incidence Rate /100 procedures 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.6% 0.5% 1.3% 3.0% 1.9% 1.2%

0%

2%

4%

6%

8%

10%

C-section SSI Incidence Rate at BC Women's Hospital

BCW : HA-SSI – CESAREAN SECTIONS

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Surveillance Definitions Colonization: The presence, growth, and multiplication of an organism without observable clinical symptoms or immune reaction. The patient is asymptomatic.

Infection: Invasion by and multiplication of a microorganism in body tissue resulting in clinical manifestations of disease.

VRE case: Laboratory confirmation of vancomycin-resistant enterococci from specimens indicative of

colonization or infection.

MRSA case: Laboratory confirmation of methicillin-resistant Staphylococcus aureus from specimens indicative of colonization or infection. This includes: Cases identified for the first time during their hospital admission to BCCH or BCW. Cases identified previously at outpatient clinics but currently the patients being admitted to BCCH

or BCW with positive MRSA isolates. Cases identified in the emergency department that are admitted subsequently (during the same

day).

This DOES NOT include: Cases identified in the emergency department but are not admitted. Cases identified in outpatient clinics or other outpatient cases. Case re-admitted with MRSA.

Healthcare-Associated MRSA: A MRSA case (as defined above) identified greater than 3 calendar days after admission to BCCH or BCW, OR a MRSA case identified 3 calendar days or less after admission to BCCH or BCW, but is related to a previous admission to BCCH or BCW within the last 12 months.

C. difficile Infection (CDI): Laboratory confirmation (positive toxin or culture with evidence of toxin production) of Clostridium difficile in an unformed stool specimen (does not include patients <1 year of age).

Primary CDI Infection: The first episode of CDI ever experienced OR a new episode of CDI which

occurs more than 8 weeks after the previous toxin-positive assay.

Continuation of the CDI infection: The subsequent positive CDI lab result(s) obtained within two weeks following the primary CDI infection.

Healthcare-Associated CDI: A CDI case (including primary and relapse CDI cases) with symptom onset greater than 3 calendar days or more after admission to BCCH or BCW, OR a CDI case with symptom onset in the community or 3 calendar days or less after admission to BCCH or BCW, provided

that symptom onset was less than 8 weeks after the last discharge from BCCH or BCW.

Unknown: A case (including MRSA, VRE or CDI as defined above) where there is insufficient information on recent healthcare exposure to classify as a Healthcare-Associated case or not.

Patient days: Patient days are used as denominators in the calculation of rates to adjust for length of stay. It is calculated by the number of patients admitted at BCCH or BCW (counts are usually conducted at midnight) and multiplied by the number of days of hospitalization in a given time period.

Incidence rate of Healthcare-Associated MRSA cases: Numerator: Number of Healthcare-Associated MRSA cases.

APPENDIX

26

Denominator: The number of patient days (excluding patients in psychiatric beds or with short-term emergency room admissions).

Incidence rate of Healthcare-Associated CDI cases: Numerator: Number of Healthcare-Associated CDI (primary cases only). Denominator: The number of patient days (excluding patients in psychiatric beds or with short-term emergency room admissions or less than one year of age).

Fiscal year/period: April 1 to March 31 of the following year.

Gastrointestinal outbreak: Three or more cases of suspected gastroenteritis among patients, residents, or staff, that cannot be explained by admitting diagnoses or by non -infectious causes of symptoms (i.e. recent use of laxatives or stool softeners, chronic diarrhea, etc.), within a four -day period in the same unit or patient care area.

Respiratory outbreak: Two or more cases of influenza-like illness (fever, chills, headache, myalgia, sore throat, cough, nasal congestion, etc.) among patients, residents, or staff within a one -week period in the same unit or patient care area.

Catheter-related Bloodstream Infection (CR-BSI):

Patient has one of the following:

Non-tunneled CVC , coated or non-coated (e.g. pulmonary artery catheter) Tunneled infusion device (e.g. Hickman, Broviac, tunneled hemodialysis line) Peripherally Inserted Central Catheter (PICC line)

IVAD

AND one of the following criteria A recognized pathogen cultured from one or more blood cultures and unrelated to an infection at

another site.

OR

At least one of: Fever >38 degrees Chills Hypotension

AND Positive laboratory results unrelated to an infection at another site that include a common skin

contaminant (e.g. diptheroids, Bacillus sp., coagulase negative staphlococci, viridians group streptococci, Aerococcus sp. and Micrococcus sp.) cultured from 2 or more blood cultures drawn on separate occasions within 48 hours of one another.

OR At least one of:

Fever >38 degrees Chills Hypotension

AND Positive laboratory results unrelated to an infection at another site that include a common skin

contaminant (e.g. diptheroids, Bacillus sp., coagulase negative staphylococci, viridians group streptococci, Aerococcus sp. and Micrococcus sp.) cultured from 1 blood culture

AND The physician institutes microbial therapy.