2011 Prince Edward Island Infection4 | Prince Edward Island Infection Prevention and Control Surveillance Report 2011 1.0 Introduction Health Care Associated Infections (HAIs) are

2011 Prince Edward Island Infection

Prevention and Control Program Report

March 2013

A special thank you to the Infection Prevention and Control Practitioners for their on-going support of the provincial surveillance program, the provincial lab, Dr. German, the Provincial Infection Prevention and Control Advisory Committee (PICPAC), the program working groups and to ITSS, in particular, Ms. Sara Townsend for ongoing technical support.

Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Section 1:

2.0 Program overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Section 2:

3.0 Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.2 Clostridium difficile in PEI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.2.1 Classification of CDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.2.2 Health Care Associated CDI (HA-CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.2.2.1 Demographic Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.2.2.2 Attributable Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3.2.3 Community Associated CDI (CA-CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

3.2.3.1 Demographic information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

3.2.4 Health Care Associated (HA-CDI) and Community Associated (CA-CDI) . . . . . . . . . . . . . . . .12

3.2.4.1 Risk Factors Health Care Associated (HA-CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

3.2.4.2 Antibiotic use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

3.2.4.3 Comparing HA-CDI and CA-CDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

3.2.4.4 Severe outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

3.2.5 CDI Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

3.3 Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

3.3.1 Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

3.4 Future Considerations for Infection Prevention and Control Surveillance on PEI . . . . . . . . . . . . . . . . . .19

4.0 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Appendix

Appendix A - MRSA data

Appendix B – Case definitions

References

Prince Edward Island Infection Prevention and Control Surveillance Report 2011 | 1

Executive SummaryIn 2008, the PEI Department of Health and Wellness identified a need to improve the administration of infection prevention and control for the province in order to meet the standards of Accreditation Canada and provide safe patient care. A province wide Infection Prevention and Control Program was developed and implemented in PEI to meet these needs.

The first section of this report provides an overview of the Provincial Infection Prevention and Control Program. The second section contains the surveillance report which provides a summary of surveillance data collected for 2011. This section will focus on data for action to reduce and prevent healthcare associated infections (HAI) and community based infections on PEI. Recommendations are made at the end of the report outlining the direction the program will take as a result of the surveillance data presented.

Program Overview

Program Goals:

1. Strengthen infection prevention and control capacity

2. Provide clear accountability

3. Develop and monitor Provincial Standards/Guidelines/Policies

4. Provide education and training to health care workers

5. Continue to develop and maintain a system for surveillance and reporting

6. Provide provincial coordination

In order to meet the goals of the program, the Provincial Infection Prevention and Control Program Advisory Committee (PICPAC) oversees 4 main working groups.

Recently, the work of the program has involved:

• Developmentofenvironmental cleaningoperational standards toensurepropercleaning inall areasofHealth PEI where patient care is provided.

• Developmentofinfectionpreventionandcontrolpoliciesforallpracticesettings.

• Expansionof thehandhygieneprogramwithall facilities (Long-TermCare,AcuteCare andCommunityHospitals) participating in 2011.

• Participationby theQueen ElizabethHospital (QEH) in theCanadianNosocomial Infection SurveillanceProgram,allowingQEHtocomparetheirratestosimilarinstitutionsnationally.

• Continueddatacollectionthroughtheprovincialsurveillancedatabase.

• Enhancedpublicreportingwithadditionofpublicwebpagethatincludesannualreports.

• ReportstostaffinHealthPEI(physicians,management,frontline)withsurveillancedata.

2 | Prince Edward Island Infection Prevention and Control Surveillance Report 2011

Surveillance Report

As part of the initial strategy, a provincial surveillance program for health care and community associated infections was established, and includes three pathogens: Methicillin-Resistant Staphylococcus aureus (MRSA), Vancomycin-Resistant Enterococci (VRE), and Clostridium difficile infection (CDI). The goal of the surveillance program is to gather relevant information on all cases, and to use this information to provide the health system with an understanding of the frequency, distribution, and risk factors associated with infections and colonizationsinPEI.Thissurveillanceinformationcanthenbeusedtoaidinpreventingandcontrollingthesepathogens in the future.

This year (2011) marks the second year for which detailed provincial surveillance information is available for Clostridium difficile infection (CDI) and the third year that Methicillin resistant Staphylococcus aureus (MRSA) is assessed. Details on CDI surveillance are included in the report; MRSA information for 2011 is available in Appendix A. The report also includes data from the provincial hand hygiene audits. These audits have been done since 2009 in all facilities across Health PEI. In this report, we will discuss trends observed since 2009, and targets for the future.

Clostridium difficile infection (CDI)

• In2011,therewere82newcasesofCDIonPEI.Thisisanincreasefrom2010(63cases).TheincreasecanbeexplainedbyachangeinthetestingprocedurethatisnowbeingdoneforC.diffintheprovince.Itisamore sensitive testing procedure which provides fewer false negative results.

• AccordingtoCanadianNosocomialInfectionSurveillanceProgram,theaverageincidenceofCDIinAtlantic Canada is 2.0/1000 admissions5. All Health PEI facilities were below this rate except for Souris Hospital who had one case for the year and no noted transmission within the facility.

• RecentantibioticusagewasthemostcommonriskfactorassociatedwithCDIwhichisconsistentwiththeliterature.

• CommunityassociatedCDI(CA-CDI)casesaresignificantlyyounger(meanage52yrs)comparedtohealthcare associated-CDI (HA-CDI) cases (mean age 68.5 yrs), and severe outcomes were more commonly reported in the HA-CDI cases than in the CA-CDI cases. This may be reflective of the significantly older age of these cases.

Hand Hygiene

• Overallhandhygiene(HH)complianceamonghealthcareworkers(HCWs)inPEIwentfrom43%in2009to73%in2011.Thisincreasemaybeduetoseveralfactors:

▪ Investments to increase access to alcohol-based hand rub (ABHR) at the point of care and throughout healthcare facilities in Health PEI

▪ Education and visual reminders in the workplace

▪ Auditing of hand hygiene practice

• AdherencetoHHbeforeandafterpatient/patientenvironmentcontactincreasedfrom2009to2011.

• AdherencetoHHafterbodyfluidexposureriskhasdecreased.

• WorkcontinuesinHealthPEItohavealcohol-basedhandrubplacedatthepointofcare,anduponentryto patient environments to support health care workers in achieving their goal of providing safe care to their patients.


RecommendationsThe following are the recommendations from this report:

• Continuecapacity building in infection prevention and control by reinforcing Routine Practices that are the cornerstone of infection prevention and control. The launch of the Routine Practices Project across Health PEI will reinforce the importance of diligent, consistent infection prevention practice to provide safe care for all users of health care services.

• Targetedhandhygieneproblemsolvingstrategiesandeducation should be focused on the 4 hand hygiene moments, especially after body fluid exposure risk. Canada’s Hand Hygiene Challenge with itsmultimodalstrategieswillcontinuetobeutilizedinordertoreachourgoalof100%compliancewith hand hygiene practice.

• Developnewinfection prevention and control practice guidelines as needed and revise present guidelines to guide the health care system on PEI into the future of infection prevention and control practice.

• Developandimprovethesurveillance system as outlined in section 3.4 in order to provide the most accurate information for program evaluation and development.


1.0 IntroductionHealth Care Associated Infections (HAIs) are a safety issue in healthcare on Prince Edward Island, across the country and around the world. It is estimated that Health Care Associated infections (HAIs) cost the Canadian health care system millions of dollars and increase length of stay in hospitals. Methicillin resistant Staphylococcus auresus (MRSA) alone costs between $42 and $59 million per year to Canadian Hospitals1. Infection prevention and control is everyone’s business. The entire health care team (administrators, physicians,frontlinehealthcareprovidersandsupportstaff),isresponsibleforpreventingHAIs.

In 2008, the PEI Department of Health identified a need to improve the administration of infection prevention and control for the province in order to meet the standards of Accreditation Canada2 and provide safe patienta care. A province wide Infection Prevention and Control (IP&C) Program was developed and implemented to meet these needs.

The first section of this report provides an overview of the Provincial Infection Prevention and Control Program and its working groups. The second section provides a summary of surveillance data. Detailed provincial surveillance information is available for Clostridium difficile Infection (CDI) and MRSA and has been available since 2010 and 2009 respectively. Details on CDI surveillance are included in the report; MRSA information for 2011 is provided in Appendix A. The case definitions for CDI and MRSA are in Appendix B. Hand hygiene audits have been performed yearly since 2009. This report will discuss hand hygiene trends since 2009 and future targets.

Recommendations are made at the end of the report outlining the direction the Infection Prevention and Control Program will take as a result of the surveillance data.

a Patient refers to patient, resident or client


Section 1

2.0 Program Overview

In 2008, the PEI Department of Health identified a need to improve infection prevention and control in the province. The Provincial Infection Prevention and Control Strategy was initiated in July of 2008 to strengthen the DepartmentofHealth’sabilitytodealeffectivelywithcurrentandemerginginfectiousdiseases.Thestrategylasted 18 months and resulted in the Provincial Infection Prevention and Control Program.

Infection Prevention and Control Program Goals:

1. Strengthen infection prevention and control capacity

2. Provide clear accountability

3. Develop and monitor Provincial Standards/Guidelines/Policies

4. Provide education and training to health care workers

5. Continue to develop and maintain a system for surveillance and reporting

6. Provide provincial coordination

The Infection Prevention and Control Program is governed by the Provincial Infection Prevention and Control Advisory Committee (PICPAC) with representatives from both Health PEI and the Department of Health and Wellness, and from all practice settings across the health care system. The Provincial Coordinator for the Program acts as a resource to the PICPAC and also facilitates the work of 4 working groups, which have been formed to carry out the Program’s work plan and meet the program goals.

Education working group

The education working group developed and implemented the provincial hand hygiene program that is highlighted in this report and develops educational tools and programs that are provincial in nature.

Infection Control Practitioner (ICP) working group

The ICP working group meets to solve professional practice issues as well as site specific and scenario specific issues that arise in day to day practice of infection prevention and control (IP&C).

Standards and Guidelines working group

The Standards and Guidelines working group develops provincial guidelines for organisms like MRSA, Vancomycin-Resistant Enterococci (VRE) and CDI. This group also reviews the Accreditation Canada standards2 and directs the work required to meet these standards. There are several sub committees that have formed from this working group. Environmental Cleaning and Public Health Dentistry subcommittees that have formed to develop policies and standards for IP&C for their areas. These subcommittees also receive guidance and assistance from the standard and guidelines working group.


Surveillance Working Group

The Surveillance working group develops assessments and reports for the provincial IP&C surveillance database. As part of the initial strategy, a province-wide surveillance program for health care and community-associated infections was established, and as of January 2010, the surveillance program includes three pathogens: Methicillin-Resistant Staphylococcus aureus (MRSA), Vancomycin-Resistant Enterococci (VRE), and Clostridium difficile (CDI). The goal of the surveillance program is to gather relevant information on all new cases, and to use this information to provide the health system with an understanding of the frequency and distributionofinfectionsandcolonizationsinPEI.Thisknowledgecanthenbeusedtoaidinpreventingandcontrolling these organisms in the future.

Recently, the work of the program has involved:

• Developmentofenvironmental cleaningoperational standards toensurepropercleaning inall areasofHealth PEI where patient care is provided.

• Developmentofinfectionpreventionandcontrolpoliciesforallpracticesettings.

• Expansionof thehandhygieneprogramwithall facilities (Long-TermCare,AcuteCare andCommunityHospitals) participating in 2011.

• Participationby theQueen ElizabethHospital (QEH) in theCanadianNosocomial Infection SurveillanceProgram,allowingQEHtocomparetheirratestosimilarinstitutionsnationally.

• Continueddatacollectionthroughtheprovincialsurveillancedatabase.

• Enhancedpublicreportingwiththeadditionofthepublicwebpagethatincludesannualreports.

• ReportstostaffinHealthPEI(physicians,management,frontline)withsurveillancedata.

The surveillance that is done within Health PEI and the community setting in PEI through the Provincial Infection Prevention and Control Program enables monitoring of new cases of MRSA, VRE, CDI and provides timely information to allow action when clusters or outbreaks of organisms occur.


Section 2

3.0 Surveillance3.1 Methods

Infection Prevention and Control Practitioners (ICP) in each health care facility and in the Chief Public Health OfficeareresponsibleforconductingsurveillanceonallnewMRSA,VREandCDIcasesoccurringintheirrespective areas of practice. Information is collected using surveillance forms developed for this purpose. The data are stored in an Infection Control electronic database, housed within the Integrated Service Management (ISM) system, which is administered by Information Technology Shared Services (ITSS). This data is then validated by the provincial epidemiology unit.

Cases identified in PEI but attributable to a facility outside of the province are excluded. Incidence rates for MRSA and CDI acquired in acute and long term care facilities are calculated using patient census information provided by the Health Information Unit, Health PEI. Although VRE is monitored in the surveillance program, the data are not included in this report as there were fewer than 5 cases reported in 2011.

In order to collect hand hygiene audit information across the province each year, a student (health care futures or student nurse) is trained using the educational tools from Canada’s Hand Hygiene Campaign3 and Canada’s Hand Hygiene Challenge4. Students are provided education on proper hand hygiene practice, use of the audit tool,anddataentry.Onsitecoachingandinter-raterreliabilitytestingisdoneaspartofthetraining.DataarecollectedonstandardizedpaperauditformsfromCanada’sHandHygieneCampaign.Anexcelspreadsheetissupplied by the campaign and used for data entry.

It is important to note that only totally viewed scenarios are recorded. For example, if the auditor views someone leaving a patient room, but did not see what took place in the room before leaving, this scenario would not be recorded at all. If the auditor views the entire care scenario in the room and sees that the Health Care Worker had not cleaned their hands after patient/patient environment contact when leaving the room, then they would record this as a missed opportunity.

3.2 Clostridium difficile in PEI

Clostridium difficile (CDI) is an intestinal bacterial infection. It is considered to be the most common cause of infectious diarrheal illness in hospitals in the developed world.5 The spores produced by Clostridium difficile can remain viable outside the human body for long periods of time; therefore rigorous infection control practicesininstitutionalsettingsareintegraltoeffectivepreventionofCDI.

The Public Health Actwasamendedin2010tomakeCDIareportablediseasetotheChiefPublicHealthOfficein Prince Edward Island.6 In 2010, a provincial guideline to direct health care workers in the management of patients with CDI was released. This guideline is available to all health care providers in both public and private health care settings on PEI. Every site is encouraged to monitor and keep track of the number of confirmed cases of CDI in order to be able to identify clusters or outbreaks.

In 2011, there were 82 new cases of CDI identified that were attributable to either a facility or to a community setting in the province. This was the second year that CDI surveillance data was available through the Infection Prevention and Control Program in PEI. In 2010, there were 63 new cases; representing an increase in case counts from 2010 to 2011. This increase can be explained by a change in testing at the provincial lab that occurredinOctober2011.Previously,testingwasdoneusingatoxinantigentestwhichwasonly60-80%sensitive,meaningthattherewasasignificantamountoffalsenegatives.OnthefirstofOctober,2011,thelabbeganusinga2stepprocessthatusesaC.diffantigenspecifictestasaninitialscreen.Apositivescreeningtestrequiresasecondtest(C.diffToxinPCR)todetermineiftheC.difforganismisproducingthetoxinthatcauses disease.


3.2.1 Classification of CDI

Cases of CDI are classified according to the setting where the patient acquired the infection (Appendix B). If the patient was in a health care facility, either an acute care hospital or a long term care facility, or frequently and regularly visiting a health care facility for ambulatory care, then the case is considered to have health care associated CDI (HA-CDI). If the patient had not had contact with a health care facility for the past 12 months, or was known not to have CDI at discharge from a health care facility, they would be considered to have community associated CDI (CA-CDI).

Table 1. CDI cases by setting, 2011, PEI (n=82)

Category Number of cases Percent

Health care associated 28 34.2%

Community associated 52 63.4%

Unknown 2 2.4%

3.2.2 Health Care Associated CDI (HA-CDI)

3.2.2.1 Demographic Information

Ofthe82casesofCDIreportedin2011,28(34%)ofthesewerecategorizedasHA-CDI.ThesameproportionofcaseswascategorizedasHA-CDIin2010.

TherewasanequalsexdistributionamongHA-CDIcases(50%female).ThemeanageofHA-CDIcaseswas69years. The mean age of female and male cases was 69.3 and 68 years, respectively. There was no statistically significantdifference(p=0.87)betweenthesexesbyagedespitethefactthattherewerenomalecasesintheyounger age categories (0-49).The sex breakdown by age category can be found in Figure 1.


Figure 1. HA-CDI cases by age and sex, PEI, 2011 (n=28)

3.2.2.2 Attributable Settings

HA-CDIcaseswerecategorizedbythehealthcaresettinginwhichtheywereacquired.Ofthe28healthcareassociatedcases,21(75%)wereacquiredinanacutecarefacility,5(16%)wereacquiredinalongtermcarefacility,and2(7%)werehealthcareassociatedwithnospecificsettingidentified.

In total 26, HA-CDI cases were attributed to a specific facility, and counts for these facilities are presented in table 2. Corresponding infection rates per 10,000 patient-days for each facility and infection rates per 1,000 admissionsforacutecarefacilitiesarealsopresented.Givendifferencesinhospitalpatientacuityandservicesprovided, it is important to note that comparisons between acute care centres in the province should not be made. In addition, caution should be taken when interpreting facility rates given the small numbers of infections per facility; one case can cause a large fluctuation in rates.

0

1

2

3

4

5

6

7

8

<20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Num

ber o

f cas

es

Age category (years)

Female

Male


Table 2. HA-CDI cases by facility, PEI, 2011 (n=26)

Facility Number of CasesRate

(per 10,000patient–days)

Rate(per 1,000

admissions)Long Term Care Prince Edward Home 4 0.9 n/a Beach Grove Home 1 0.2 n/a

Acute Care Queen Elizabeth Hospital 16 2.1 1.7 Prince County Hospital 2 0.6 0.5 Western Hospital 1 1.3 1.5 Kings County Memorial Hospital 1 1.0 1.8 Souris Hospital 1 2.2 2.5

Note:FacilitiesthathadzerocasesofCDIattributedarenotlistedaboveastheirratewas0;howevertheywereincluded in the denominator for the overall rate calculation. This does not include cases where attributable settingwasnotidentified(n=2).


3.2.3 Community Associated CDI (CA-CDI)

3.2.3.1 Demographic Information

Ofthe82casesofCDIreportedin2011,52(63%)ofthesewerecategorizedasCA-CDI.ThesameproportionofcaseswascategorizedasCA-CDIin2010.

The mean age of CA-CDI cases was 52 years. The mean age of female and male cases was 54 and 49 years, respectively.Therewasnostatisticallysignificantdifference(p=0.39)betweenthesexesbyagedespitedifferentmeanages.ThesexbreakdownbyagecategorycanbefoundinFigure2.

Figure 2. CA-CDI cases, by age and sex, PEI, 2011 (n=52)

0

2

4

6

8

10

12

14

<20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Num

ber o

f cas

es

Age group

Female

Male


3.2.4 Health Care Associated (HA-CDI) and Community Associated (CA-CDI)

3.2.4.1 Risk Factors

The most common risk factors cited in the literature for CDI are previous antibiotic usage (particularly broad spectrum), increased age, and individuals with serious underlying illness or debilitation.7 As part of the surveillance system, cases are assessed on risk factors that are known to be associated with CDI acquisition (Table 3).

The most commonly reported risk factors for both HA and CA-CDI were history of antibiotics in the past 60 daysandpriorhospitalization.Whiletheseareseparateriskfactors,itshouldbenotedthatwhereknown,61%ofthepriorhospitalizedcaseshadahistoryofantibioticusage,sotheseriskfactorsmaybeconfounding.

Priorhospitalizationwasthesecondmostcommonriskfactorcited,whetherornotthecasewascategorizedCA-CDI, which may indicate a need to revise the assessment form for CDI and ensure the parameters around this risk factor are clear.

Table 3. Risk Factors in HA-CDI and CA-CDI Cases (n=80)

Risk Factor HA-CDI (n=28) CA-CDI (n=52)

History of Antibiotics in past 60 days 22 (78.6%) 35 (67.3%)

Prolonged Hospitalization (>2 weeks in past 2 months) 9 (32.1%) 1 (1.9%)

Prior Hospitalization 8 (28.6%) 7 (13.5%)

History of Proton Pump Inhibitor 7 (21.9%) 7 (13.5%)

Chemotherapy 5 (15.6%) 4 (7.7%)

ICU Hospitalization 4 (14.3%) 1 (1.9%)

Bowel Surgery 1 (3.1%) 3 (5.8%)

Note: Percentages based on proportion of cases with specific risk factor divided by the total number of cases by case type. For example, 22 HA-CDI cases had a history of antibiotic use out of a total of 28 HA-CDI cases (22/28=78.6%).

(n=2notincludedwhereHA/CAnotdetermined)


3.2.4.2 Antibiotic use

Antibiotics are a common risk factor for CDI because they cause a disruption in the normal colonic flora allowing infection with C. difficile to take hold. This is most often associated with broad spectrum antibiotics such as penicillins, fluroquinolones, clindamycin and cephalosporins.8Forthisreason,CDIisoftencategorizedas an antibiotic associated disease.

To further explore antibiotic usage, a breakdown of types is presented in Table 4. Consistent with the literature, CDI in PEI is associated most commonly with broad-spectrum antibiotics. Fluroquinolones were most often prescribed for HA-CDI, compared to clindamycin for CA-CDI.

Table 4. Types of Historic Antibiotics in HA- and CA-CDI Cases

Antibiotic HA-CDI (n%) CA-CDI (n%)

Fluoroquinolones 9 (32.1%) 10 (19.2%)

Cephalosporins 5 (17.9 %) 5 (9.6%)

Clindamycin 5 (17.9%) 12 (23.1%)

Penicillins 4 (14.3%) 10 (19.2%)

Sulfa drugs 3 (10.7%) 1 (1.9%)

Gentamicin 2 (7.1%) 0 (0%)

Metronidazole 1 (3.6%) 5 (9.6%)

Vancomycin 1 (3.6%) 0 (0%)

Meropenem 1 (3.6%) 0 (0%)

Nitrofurantoin 0 1 (1.9%)

Any antibiotic 22 (78.6%) 35 (67.3%)

Note: Percentages based on proportion of cases with specific risk factor divided by the total number of cases by case type. For example, 9 HA-CDI cases had a history of fluoroquinolone use out of a total of 28 HA-CDI cases(9/28=32.1%).

Four cases had a history of antibiotic use listed; however, the drug(s) were not specified.

3.2.4.3 Comparing HA-CDI and CA-CDI cases

ItisimportanttounderstandwherecasescontractedCDIinordertoeffectivelytargetpublichealthaction.CasesofHAandCA-CDIwereanalyzedtodeterminedifferencesbetweenthem.ThereisastatisticallysignificantdifferencebetweenHAandCA-CDIcasesintermsofage.CA-CDIaresignificantlyyoungercompared to HA-CDI cases.

OtherstatisticallysignificantdifferencesnotedbetweenHAandCA-CDIwere:

• historyofprolongedhospitalization

• ICUadmission

These risk factors would apply most often to HA-CDI cases due to the case definitions of CA vs. HA CDI thus they would be expected.


Table 5. Difference between HA and CA-CDI, PEI, 2011 (HA-CDI n=28; CA-CDI n=52)

Variable HA-CDI CA-CDI p-value

Sex

Male 14 18 0.9

Female 14 34

Age

0-59 7 34 <0.001

60+ 21 18

History of Antibiotics

Yes 21 35 0.6

No 3 10

Unknown 4 6

Requires colectomy

Yes 1 0 0.2

No 27 51

History of PPI

Yes 7 7 0.4

No 18 39

Unknown 3 5

History of chemotherapy

Yes 5 4 0.4

No 21 44

Unknown 2 4

History of bowel surgery

Yes 1 3 0.8

No 26 46

Unknown 1 3

Prolonged hospitalization

Yes 9 1 <0.0001

No 17 51

Unknown 2 0

Prior hospitalization

Yes 9 7 0.2

No 19 44

Unknown 1 1

ICU admission

Yes, due to CDI 0 0 0.03

Yes, not due to CDI 4 1

No 24 50


3.2.4.4 Severe outcomes

As CDI is a common cause of significant morbidity and mortality, it is important to conduct surveillance on severe outcomes.8 A Canadian survey conducted between 2004 and 2005 found that 30 days post-onset of HA-CDI,16%ofpatientshaddiedfromallcauses,with5.7%attributedeitherdirectlyorindirectlytoHA-CDI.8 Similartothisstudy,PEIsaw2casesor7.1%ofallcasesofHA-CDIhadtheirdeathattributedtoCDI.Ithasalso been noted that while rates of HA-CDI seem stable in Canada, severe outcomes associated with CDI has increased dramatically over the past 10-15 years.8 We will continue to monitor for severe outcomes from CDI in Prince Edward Island healthcare facilities.

Ofthe28HA-CDIcasesinPEI,4requiredICUadmissionsforreasonsotherthanCDI,2remainedinhospitaldue to CDI 30 days post-diagnosis, and 3 remained in hospital 30 days post-diagnosis for non-CDI reasons. In total, 5 cases died within 30 days of CDI diagnosis; 2 of these deaths were attributed to CDI.

Table 6. HA and CA-CDI outcomes, PEI, 2011 (HA-CDI n=28; CA-CDI n=52)

Outcome HA-CDI (n=28) CA-CDI (n=52)

Required ICU admission other cause 4 (14.3%) 1 (1.9%)

In hospital 30 days post diagnosis due to CDI 2 (7.1%) 0

In hospital 30 days post diagnosis due to other cause 3 (10.7%) 0

Deceased due to CDI 2 (7.1%) 0

Deceased due to other cause 3 (10.7%) 0

Unknown 2 (7.1%) 17 (32.7%)

3.2.5 CDI Summary

The previous sections discussed the risk factors for CDI and the severe outcomes we have seen on PEI. CDI costs the health care system in increased length of stay for some patients as well as in medication costs for treatmentandunduesufferingtoourclients/patients/residents.Asthisorganismisantibioticassociated,judicioususeofantibioticsisessentialtominimizethecosttoourpatientsandthehealthcaresystem.Itisimportant to note that although CDI can occur with appropriate use of antibiotics, antibiotic stewardship should be exercised to prevent the potential occurrence of CDI whenever possible.

3.3 Hand Hygiene

3.3.1 Description

Hand hygiene (HH) refers to removing or killing microorganisms (i.e., germs) on the hands. When performed correctly,handhygieneisthesinglemosteffectivewaytopreventthespreadofcommunicablediseasesandinfections. In health care, hand hygiene is used to eliminate transient microorganisms that have been picked up via contact with patients contaminated equipment or the environment. Hand hygiene may be performed by using soap and running water, or with alcohol-based hand rubs (ABHR).9

Hand hygiene is the responsibility of all individuals involved in health care in order to reduce the risk of health careacquiredinfectionsandtheirimpactacrossthecontinuumofcare.Giventheavailabilityofsufficienthandhygienesuppliesandopportunities,100%complianceisthegoalforallhealthcareproviderswhocomeinphysical contact with patients and their environments.

The Provincial Infection Prevention and Control Program adopted “Canada’s Hand Hygiene Campaign” in 2008.3 This campaign is evidence based, multimodal and includes educational materials, posters and audit forms. The program also provides instructions for auditing and an excel spreadsheet with prebuilt reports.


Educationisprovidedtostaffbytheinfectionpreventionandcontrolpractitioners(ICPs)inhealthcarefacilities across Health PEI. In 2010, this program was expanded to include a “Human Factors Toolkit” and renamed Canada’s Hand Hygiene Challenge.4

The data is collected across all facilities (long term care, acute care and community hospitals) in Health PEI. Thestudentsaretrainedbythesamepersonusingthesametrainingprogram.TheQueenElizabethHospitaldatawasnotincludedinthe2009and2010analyses,asaslightlydifferentmethodologyforauditingwasimplemented in that facility; however, the 2011 data includes all facilities in Health PEI.

Nationally,weknowthathandhygieneratesareapproximately40%forhealthcareproviders.3 This is also true in most developed countries where hand hygiene is monitored.10 Hand hygiene rates in PEI are above the nationalaverage,butnotcloseenoughtothetargetof100%.Eachyear,theratesarepostedineachfacilityand are used for targeted education and problem solving.

As demonstrated in Figure 3, the rates for hand hygiene by health care provider type have been improving. It is important to note that some categories, such as medical students do not have many observations and therefore vary widely from year to year. Physicians have the lowest hand hygiene adherence rates.

OverallhandhygienecomplianceamongHCWsinPEIwentfrom43%in2009to73%in2011.Thisincreasemay be due to several factors:

▪ Investments to increase access to alcohol based hand rub (ABHR) at the point of care and throughout healthcare facilities in Health PEI

▪ Education and visual reminders in the workplace

▪ Auditing and feedback of hand hygiene practice


Figure 3. Overall hand hygiene compliance rates (%) by health care provider type, acute and long term care facilities, PEI, 2009-2011

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Allied HCPs* Environmental Services

Medical Students

Nurses Nursing Students

Patient Transporters

Physicians Other

Com

plia

nce

Rat

e

2009

2010

2011

2009 n= 26 364 2 1451 284 17 53 233 2010 n= 69 289 6 1764 302 9 83 242 2011 n= 177 232 9 2155 228 9 111 216

NOTE:tablecontainsnumberofobservationsforeachhealthcareprovidercategory

*IncludesPhysicalTherapists,OccupationalTherapists,SpeechTherapy,RespiratoryTherapists,SocialWorkers,PastoralCare,BloodCollection/Lab,andRadiology.

Note:2009and2010handhygienedataexcludesQueenElizabethHospitalastheyhadaslightlydifferentmethodology for auditing.

Figure 4 shows hand hygiene adherence according to the 4 moments for hand hygiene.3,4

The 4 moments are as follows:

1. Before initial patient/patient environment contact – When entering, before touching the patient or any object or furniture in the patient environment. This moment is important to protect the patient/patient environment from harmful organisms carried on caregivers’ hands.

2. Before aseptic procedure – Immediately before any aseptic procedure. This moment is important to protect the patient against harmful organisms, including the patient’s own organisms, entering his or her


body. This moment would involve “touching/manipulating a body site that should be protected against anycolonizations(e.g.,woundcareincludingdressingchangeandwoundassessment),ormanipulatinganinvasivedevicethatcouldresultincolonizationofabodyarethatshouldbeprotectedagainstcolonization(e.g.,primingintravenousinfusionset,insertingspikeintoopeningofIVbag,flushingline,adjusting intravenous site, administering medication through IV port, changing IV tubing)”.3

3. After body fluid exposure risk – to protect the care giver and the health care environment from harmful patient organisms (e.g., after contact with blood or blood products, emptying urinal/catheter bag and suctioning oral/nasal secretions).

4. After patient/patient environment contact – When leaving after touching patient or any object or furniture in the patient’s environment. This moment is important to protect the caregiver and the health care environment from harmful patient organisms.

Figure 4. Hand hygiene compliance rates by four observation moments, PEI, acute care and long-term care facilities, 2009-2011

0%

10%

20%

30%

40%

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Before initial patient/patient

environment contact

Before aseptic procedure After body fluid exposure risk

After patient/patient environment contact

Com

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rate

Observation moment

Hand hygiene compliance rates by four observation moments, PEI, acute care and long term care facilities, 2009-2011

2009

2010

2011

2009 n= 1536 6 71 1885 2010 n= 1171 24 110 1549 2011 n= 1321 42 89 2171

NOTE:tablecontainsnumberofobservationsforeachofthe4handhygienemoments

Note:2009and2010handhygienedataexcludesQueenElizabethHospitalastheyhadaslightlydifferentmethodology for auditing.


Adherence to hand hygiene before and after patient /patient environment contact increased significantly from 2009 to 2011.

Conversely, adherence to hand hygiene practice after body fluid exposure risk has shown a statistically significant decrease. HCW are most likely to clean their hands when visibly dirty. When there is a risk of body fluid exposure but no visible signs of contamination are present, this opportunity may be missed. Body fluid exposure risk can occur in any health care setting thus enhanced education and attention to this opportunity must occur.

It should be noted, as aseptic procedures occur most often in the acute care setting, there are low numbers of observations.

3.4 Future Considerations for Infection Prevention and Control Surveillance

Data quality issues have highlighted some areas on the surveillance assessments that need to be revisited. Examining the data also demonstrates some gaps in data, whereby certain risk factor information may need toberemovedifitcannotbeadequatelyassessed.Ofnoteparticularlywasthepotentialmisclassificationofsome CDI cases as community-associated when there were clear health-associated risk factors. Reviewing and revising the assessments and case definitions as needed will help remedy these issues.

This is the first year that a detailed MRSA report was not produced. In the coming years we will be adding to the antibiotic resistant organisms under surveillance, and begin including Extended- Spectrum Beta Lactamase(ESBL)andotherorganismsofinterest.Asnotedinlastyears’report,practicesettingspecificsurveillance such as ventilator-associated pneumonias, surgical site infections, catheter line infections in the acute setting, urinary tract infections, upper respiratory infections and skin and soft tissue infections in the long-term setting will be considered for future reports with the assistance of physicians, nurses and other health care providers.

4. RecommendationsThe following are the recommendations from this report:

• ContinuecapacitybuildingininfectionpreventionandcontrolbyreinforcingRoutinePracticeswhichare the cornerstone of infection prevention and control. The launch of the Routine Practices Project across Health PEI will reinforce the importance of diligent, consistent infection prevention practice to provide safe care for all users of health care services.

• Targetedhandhygieneproblemsolvingstrategiesandeducationshouldbefocusedonthe4handhygiene moments, especially after body fluid exposure risk. Canada’s Hand Hygiene Challenge with itsmultimodalstrategieswillcontinuetobeutilizedinordertoreachourgoalof100%compliancewith hand hygiene practice.

• Developnewinfectionpreventionandcontrolpracticeguidelinesasneededandrevisepresentguidelines to guide the health care system on PEI into the future of infection prevention and control practice.

• Developandimprovethesurveillancesystemasoutlinedinsection3.4inordertoprovidethemostaccurate information for program evaluation and development.


Appendix

Appendix A – MRSA data

Figure 1:

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011MRSA 10 13 44 62 113 107 191 182 215 205

0

50

100

150

200

250

Number of Cases

MRSA Cases by Year, PE 2002-2012

Figure 2:

PercentageofMRSACasesbycolonizationorinfection

Table 1. Health Care- and Community-Associated Cases of MRSA, PE 2009-2011

2009 2010 2011Health Care Associated MRSA 135 141 161Community Associated MRSA 47 74 44

Table 2. MRSA Rates in Long Term Care and Mental Health Facilities, PE 2009-2011

2009 2010 2011Long Term Care Facilities

Beach Grove Home 2.7 0.6 1.0Prince Edward Home 3.0 0.6 0.4

Summerset Manor 0 0.3 0.7Wedgewood Manor 0.7 0.7 3.3*

Mental Health FacilitiesHillsborough Hospital 0 0 3.7*

*Both Wedgewood Manor and Hillsborough Hospital experienced MRSA outbreaks during 2011.

Table 3. MRSA Rates in Acute Care, PE 2009-2011

Rate (per 10,000 patient-days) Rate (per 1,000 admissions)2009 2010 2011 2009 2010 2011

Kings County Memorial 2.1 0 2.0 3.5 0 3.5Prince County 5.6 8.3 2.5 4.7 5.9 1.9Queen Elizabeth 8.3 9.2 6.7 6.8 7.5 5.4Stewart Memorial 1.5 1.7 0 8.0 7.8 0Souris 0 2.1 4.3 0 3.1 5.0Western 1.3 1.3 0 1.3 1.3 0

Appendix B – Case definitions

Case Definition For MRSA

A case of MRSA is defined as MRSA (Methicillin Resistant Staphylococcus aureus) isolated from any body site on an individual.

A new case of Healthcare Associated MRSA is defined as MRSA isolated from a patient with these health-care associated risk factors:

1. Hospitalization>48hrsbeforespecimencollection2.Priorhistoryofsurgery,dialysisorhospitalization/residenceinotherhealthcarefacilityinthepast12

months3. Presence of a percutaneous device or indwelling catheter at time of specimen collection

HealthCareAssociated(Nosocomial):ThosenewcasesofMRSAwhomeettheabovecriteriawhoaredetermined by the ICP to have acquired MRSA in a hospital.

HealthCareAssociated(Non-Nosocomial):ThosecasesofMRSAinanon-acutecaresetting.

A new case of Community Associated MRSA is defined as MRSA isolated from a clinical specimen of a patient without the established health-care related risk factors including:

1.Hospitalization>48hrsbeforespecimencollection2.Priorhistoryofsurgery,dialysisorhospitalization/residenceinotherhealthcarefacilityinthepast12

months3. Presence of a percutaneous device or indwelling catheter at time of specimen collection4.PrevioushistoryofMRSAcolonizationorinfection

Whether a case is classified as an infection or colonization depends on whether the patient has evidence of signs and/or symptoms at the MRSA positive site.

BasedonCNISPdefinition

Case Definition for Clostridium difficile associated disease (CDAD)

Diarrhea and laboratory confirmation of a positive toxin assay for C. difficile;OR

Visualizationofpseudomembranesonsigmoidoscopyforcolonoscopy,orhistological/pathologicaldiagnosisof CDAD.

Diarrhea will be defined as one of the following:Three or more loose/watery* bowel movements in a 24 hour period, and Thebowelmovementsareunusualordifferentforthepatient,andThereisnootherrecognizedetiologyforthediarrhea(forexample,laxativeuse,andinflammatorybowel disease)

*Loose/watery:ifthestoolweretobepouredintoacontainer,itwouldconformtotheshapeofthecontainer.

Health Care AssociatedSymptoms were not present on admission (onset of symptoms greater than 72hours after admission) and therewasnoadmissiontoanACorLTCfacilityinthelast4weeks(ifthept/residentwasinanotherfacilityinthe past 4 weeks, the case may be attributed to that facility). Community AcquiredSymptomonsetinthecommunityorlessthan72hoursafterbeingadmittedtoanACorLTCfacility,andsymptomonsetwasmorethan4weekspostdischargefromanAC/LTCfacility.

Recurrent caseIndividuals who have a second confirmed episode of CDAD between the end of treatment and 4 weeks (28 days) from the end of treatment of the first episode, are classified as recurrent cases.

If the second episode is greater than 4 weeks (28 days) from the end of treatment date, it is no longer considered a recurrence. It is classified as a new case.

References

1.Kim,T.,Oh,P.I.,andSimor,A.E.(2001).The economic impact of methicillin-resistant Staphyloccus aureus in Canadian hospitals. Infection Control and Hospital Epidemiology, 22(2), 99-104.

2. Accreditation Canada. (2012) Qmentum Standards for Infection Prevention and Control.

3. Canadian Patient Safety Institute. (2008) Canada’s Hand Hygiene Campaign.

4. Canadian Patient Safety Institute. (2010) Canada’s Hand Hygiene Challenge.

5. Simor, A., E (2012) Clostridium difficile Infection: Canadian Epidemiology, 2012. Accessed at: http://www.oahpp.ca/resources/documents/presentations/2012may28-29/2.0%20-%20Epi%20

Data/CdiffCanEpi2012.pdf OnMarch22,2013

6. Prince Edward Island Public Health Act,NotifiableandCommunicableDiseasesRegulations,Cap.P-30.

7. Schroeder M. (2005) Clostridium difficile-Associated Diarrhea. Amer. Fam. Physician, 71(5):921.

8. Gravel D, Miller M, Simor A., Taylor G, et al. 2009. Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: A Canadian Nosocomial Infection Surveillance Program Study.

Clin Inf Dis, 48:568.

9. Community and Hospital Infection Control Association (CHICA)-Canada Standards and Guidelines Core Committee. (2008) Hand Hygiene Position Statement. Accessed at: www.chica.org/pdf/handhygiene.pdf on February 11, 2013

10.WorldHealthOrganization.(2009) WHOGuidelinesonHandHygieneinHealthCare:FirstGlobalPatientSafety Challenge. Clean Care is Safer Care.

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2011 Prince Edward Island Infection4 | Prince Edward Island Infection Prevention and Control Surveillance Report 2011 1.0 Introduction Health Care Associated Infections (HAIs) are

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