ANNUAL REPORT

Prepared by:

Provincial Health Services Authority Infection Prevention & Control

August 2016

April 2015 – March 2016

INFECTION PREVENTION AND CONTROL

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Table of Contents

Table of Contents .......................................................................................................................................... 1

Executive Summary ....................................................................................................................................... 2

PHSA Infection Prevention and Control Program ......................................................................................... 3

Knowledge Translation ................................................................................................................................. 7

Hand Hygiene Program ............................................................................................................................... 11

Cleaning, Disinfection and Sterilization ...................................................................................................... 12

Construction Consultation .......................................................................................................................... 14

Surveillance ................................................................................................................................................. 15

Outbreak Management............................................................................................................................... 21

Projects and Initiatives ................................................................................................................................ 22

Future Directions ........................................................................................................................................ 24

Appendix A – PHSA IPAC Organizational Chart ........................................................................................... 26

Appendix B – Definitions ............................................................................................................................. 27

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Executive Summary At the Provincial Health Services Authority (PHSA), the safety of patients, staff and visitors is of ultimate importance. To help meet this commitment, a PHSA Infection Prevention and Control (IPAC) Service was formed in 2006, reporting to the PHSA VP of Quality and Safety. The IPAC team works collaboratively with other groups within PHSA, other health authorities, the Provincial Infection Control Network of BC (PICNet), and regional and national public health services in supporting best practices to prevent and control infections at PHSA facilities. The IPAC team is involved in a variety of activities that include:

• Knowledge translation (education and research) • Hand hygiene program • Surveillance • Outbreak management • Construction consultation • Cleaning, disinfection and sterilization • Policy and procedure development

During 2015-16, the IPAC team participated in additional projects and initiatives such as: • Conducting a PHSA-wide survey on staff perceptions of the IPAC Service • Implementation of the UV-C disinfection machine at BC Children’s Hospital • Development of a new C-section surveillance system at BC Women’s Hospital + Health

Centre The following table highlights trends in HAI rates for 2015-16: Indicator 2014-15 Rate 2015-16 Rate PHSA Overall Hand Hygiene Compliance 90% 92%

PHSA HA-CDI Rate 6.9 per 10,000 inpatient days

6.4 per 10,000 inpatient days

PHSA HA-MRSA Rate 2.3 per 10,000 inpatient days

2.9 per 10,000 inpatient days

PHSA HA-VRE Rate 0.5 per 10,000 inpatient days

1.7 per 10,000 inpatient days

CRBSI Rate in PICU 0.6 per 1,000 catheter days

1.6 per 1,000 catheter days

CRBSI Rate in NICU 2.4 per 1,000 catheter days

5.0 per 1,000 catheter days

*NOTE: None of the above rate changes are statistically significant.

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PHSA Infection Prevention and Control Program

Our vision: Empowering everyone to prevent infections. These words paint a picture of the world the Infection Prevention and Control (IPAC) Service seeks to create. Our vision captures the notion that each person in the healthcare team has a role to play in the prevention of infections. Our goal is to ensure that everyone has the knowledge and confidence to participate in infection prevention.

Our mission: Our mission is to ensure the protection of patients, staff and visitors from preventable infections. We aim to achieve this through:

• A proactive approach to current and evolving challenges • Facilitating implementations and solutions • Expert consultation based on applicable regulations, evidence and best practice • Collaborating with local, provincial, and national partners

Our services: Knowledge Translation Hand Hygiene Program Surveillance Outbreak Management Construction Consultation Cleaning, Disinfection and Sterilization Projects and Initiatives Policies and procedures

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PHSA Infection Prevention and Control Team 2015-16

Georgene Miller, RN, MSN Vice President Quality Safety and Outcome Improvement

Jocelyn Srigley, MD, FRCPC Corporate Director, PHSA IPAC Medical Microbiologist

Ghada Al-Rawahi, MD, FRCPC IPAC Medical Lead, BCCA Medical Microbiologist Simon Dobson, MD, FRCPC Infection Control Officer Infectious Diseases Specialist

Peter Tilley, MD, FRCPC Infection Control Officer Medical Microbiologist

David Goldfarb, MD, FRCPC Infection Control Officer Medical Microbiologist

Robyn Hunter, RN, CIC PHSA IPAC Coordinator Stacie Buttar, HR IPAC Administrative Assistant Jun Chen Collet, BMed, MSc IPAC Epidemiologist

Viola Tang, RN IPAC Reprocessing Manager Sarah Wells, BHSc, CIC IPAC Construction Specialist

Louise Holmes, RN, BSN Clinical Project Lead – Redevelopment Marney Hunt, RN, BSN Infection Control Practitioner, BCCH & BCWH

Charina Rivas, RN, BSN Infection Control Practitioner, BCCH & BCWH

Michelle Chang, RN, MPH Infection Control Practitioner, BCCH &BCWH

Julita Sienkiewicz, RN, BSN Infection Control Practitioner, BCCH & BCWH

Alison Chant, RN, CIC Infection Control Practitioner, BCCA Kimberly Mallory, RN, CIC Infection Control Practitioner, BCCA

Sheetal Kainth, RN Infection Control Practitioner, BCCA

Kristie Harding, RN Infection Control Practitioner, BCCA

Judy Tearoe, RN Infection Control Practitioner, BCCA

Adriana Mendes, RN, CIC Infection Control Practitioner, BCCA

May Tang, RN Infection Control Practitioner, BCCA KaWai Leung, RN, MPH Infection Control Practitioner, BCCA

Ron Morley, RPN, ADPN Infection Control Practitioner, Forensics Lisa Young, RN, BA(Hons) Leader, IPAC, BCEHS

Carmen Saucier Hand Hygiene Auditor, Co-op Student Rishi Chatterjee Hand Hygiene Auditor, Co-op Student Cherrie Lo Hand Hygiene Auditor, Co-op Student Sanjam Jhawar

Hand Hygiene Auditor, Co-op Student

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Our Facilities:

BC Centre for Disease Control: New Westminster and Vancouver Clinics

Annual outpatient visits TB Clinic: 20,568 Annual outpatient visits STD Clinic: 18,277

BC Children’s Hospital Acute care beds: 102

Annual admissions: 6,587 Annual outpatient visits: 130,578

BC Child and Youth Mental Health

Acute care beds: 40 Annual admissions: 395

Annual outpatient visits: 17,103

Sunny Hill Health Centre for Children

Acute care beds: 14 Annual admissions: 134

Annual outpatient visits: 10,929

BC Women’s Hospital Acute care beds: 130

Annual admissions: 16,177 Annual outpatient visits: 60,373

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BC Cancer Agency Vancouver Centre* Acute care beds: 26

Annual admissions: 729 Annual outpatient visits: 126,558

BC Cancer Agency Vancouver Island Centre*

Acute care beds: N/A Annual admissions: N/A

Annual outpatient visits: 69,789

BC Cancer Agency Abbotsford Centre* Acute care beds: N/A

Annual admissions: N/A Annual outpatient visits: 43,171

BC Cancer Agency Centre of the Southern

Interior* Acute care beds: N/A

Annual admissions: N/A Annual outpatient visits: 50,923

BC Cancer Agency Centre of the North*

Acute care beds: N/A Annual admissions: N/A

Annual outpatient visits: 18,195

BC Cancer Agency Fraser Valley Centre* Acute care beds: N/A

Annual admissions: N/A Annual outpatient visits: 61,146

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BC Forensic Psychiatric Hospital Acute care beds: 190

Annual admissions: 283 Annual outpatient visits: 2,590

BC Emergency Health Services (A division supported by PHSA)

# Ambulances dispatched: 545,000 # Air ambulance annual calls: 6,700

N/A indicates that this activity is not applicable. *The outpatient visits for BCCA are the sum of the radiation therapy visits, systemic therapy visits and chemotherapy visits.

Source: Data provided by PHSA Performance Measurement and Reporting Group.

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Knowledge Translation

Staff, Volunteer, Patient, Family, and Visitor Education Education is an essential component of IPAC. The IPAC team delivers education sessions to all new employees during orientation and provides ongoing education to all PHSA staff. During 2015-16, IPAC provided 9,090 hours of educational sessions for 2,118 staff. In addition to didactic sessions, the infection control practitioners (ICPs) address patient-, procedure-, or unit-specific concerns on a daily basis through phone consultation and ward visits.

International Infection Control Week (October 19-23, 2015) was another opportunity to provide education to staff, as well as volunteers, patients, families and visitors. Daily newsletters were sent to all staff on topics that included methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. difficile) infection, influenza, and shingles (herpes zoster).

The IPAC team is continually developing, assessing and revising education material and strategies to meet learning needs. The BC Infection Control and Hand Hygiene course, Hand Hygiene for Medical Staff, and Provincial Hand Hygiene Basics are available online for all staff through the Learning Hub (https://learninghub.phsa.ca/ ). Information sheets on IPAC topics are available for staff, patients, families, and visitors through the PHSA Libraries (https://libraries.phsa.ca/).

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Continuing Education for the IPAC Team

IPAC leadership encourages self-led knowledge enhancement and development to ensure that all team members remain up to date with IPAC best practices. Support is provided for team members to attend various learning opportunities such as national infection control education conferences (IPAC Canada), provincial educational days (e.g. Provincial Infection Control Network , IPAC-BC), Canadian Standards Association seminars, web teleclasses, Infectious Diseases/Medical Microbiology rounds at BC Children’s and BC Women’s and Oncology rounds at BC Cancer Agency. In addition, Dr. Michael Gardam, Director of IPAC at the University Health Network in Toronto was invited to present to the team in November 2015 on the topic of frontline ownership and culture change.

IPAC team members are also encouraged to pursue formal education and certification programs (e.g. Certification in Infection Control).

Research Activities: Peer-reviewed publications: Leduc S, Busch K, Campbell J, Cassidy K, Collet JC, Forrester L, Henderson E, Leal J, Leamon A, Pelude L, Mitchell R, Mukhi SN, Quach-Thanh C, Shurgold JY, Simmonds K. What can an audit of national surveillance data tell us? Findings from an audit of Canadian vancomycin-resistant enterococci surveillance data. Canadian J Infect Control 2015; 30(2):75-81. Srigley JA, Corace K, Hargadon DP, Yu D, MacDonald T, Fabrigar L, Garber G. Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review. J Hosp Infect 2015;91(3):202-10. Conference abstracts: Wong F, Prestley N, Dhillon S, Albert A, Collet JC, Thomas E, Van Schalkwyk J, Money D, Dewar K, Hippman C, Shaw D, Giesbrecht E. Improving post-discharge surveillance of surgical site infection following caesarean section at BC Women’s Hospital. Poster presentation at Quality Forum, Vancouver, British Columbia. February 2015. Lavie-Nevo K, Ting JY, Al-Rawahi G, Paquette V, Osiovich H, Dobson S, Roberts A. Prevalence and clinical impact of methicillin-resistant Staphylococcus aureus colonization and infection among infants at a level III neonatal intensive care unit. Poster presentation at Pediatric Academic Societies’ Meeting, San Diego, California. April 2015.

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Harding K, Al-Rawahi G, Chant A, Hunter R, Tearoe J, Ryder B, Kainth S. Genetically modified micro-organisms to treat cancer: infection control implications. Poster presented at IPAC Canada National Education Conference, Victoria, British Columbia. June 2015.

Laporte K, Collet JC, Thomas E, Tilley P, Dobson S, Hunter R, Hunt M, Al-Rawahi G. A norovirus outbreak amongst a pediatric oncology patient population. Poster presented at IPAC Canada National Education Conference, Victoria, British Columbia. June 2015. Lloyd-Smith E, Collet JC, Donovan T, Forrester L, Han G, Leamon A, Mori J. Formation of Infection Control Epidemiologists in British Columbia: setting the stage for collaboration. Oral presentation by L Forrester at IPAC Canada National Education Conference, Victoria, British Columbia. June 2015. Srigley JA, Corace K, Hargadon DP, Yu D, MacDonald T, Fabrigar L, Garber G. Can behaviour change theory help us improve healthcare worker hand hygiene compliance? A systematic review. Oral presentation by K. Corace at IPAC Canada National Education Conference, Victoria, British Columbia. June 2015. Corace K, Srigley JA, Hargadon DP, Yu D, MacDonald T, Fabrigar L, Garber G. Can behavior change frameworks improve healthcare worker influenza vaccination uptake? A systematic review. Poster presentation at IDWeek 2015, San Diego, California. October 2015. Bedford J, Ting J, Paquette V, Ng K, Tilley P, Murthy S, Rassekh S, Kang K, Osiovich H, Roberts A, Skarsgard E, Dobson S, Ting J. Antimicrobial prophylaxis and the risk of surgical site infections: a national surgical quality improvement program-pediatrics (NSQIP) analysis. Poster presentation at World Congress of Pediatric Infectious Diseases Annual Conference, Rio De Janerio, Brazil. November 2015.

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Collaborations: Since 2002, BC Children’s Hospital and BC Women’s Hospital + Health Centre have actively participating in the Canadian Nosocomial Infection Surveillance Program’s surveillance and research initiatives. The IPAC team will continue to contribute to this national collaboration and help our national colleagues to generate evidence-based data that can be used to establish benchmarks, identify trends, and develop provincial/national guidelines to help reduce the transmission of HAIs. In 2015, PHSA IPAC joined the Society for Healthcare Epidemiology of America (SHEA) Research Network, an international consortium of over 100 facilities collaborating on multi-centre research projects. IPAC team members participated in a number of surveys through this network. In early 2016, PHSA was recognized by the SHEA Research Network as being a top contributor. On February 16, 2016, the IPAC team at BCWH participated in a national antibiotic resistant organism (ARO) point prevalence survey. This was a follow-up to similar surveys that occurred in 2010 and 2012, with the aim of defining the burden of AROs in Canadian hospitals, and in particular to further determine trends and changes that occur over time. Publication of the results is anticipated in the next fiscal year.

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Hand Hygiene Program Hand Hygiene is considered an important intervention to prevent the spread of healthcare-associated infections. The PHSA hand Hygiene (HH) program began in 2008.

The BC Ministry of Health Best Practices for Hand Hygiene document guides hand hygiene practice for all facilities at PHSA.

Major HH Activities in 2015-16: Update of electronic HH auditing system. A celebration of World HH Day occurred in May. The

focus was on encouraging PHSA staff to submit HH-related photos to the Canada-wide “Clean Shots” campaign.

Audits continue to be done quarterly with outstanding results. Major refresh of the promotional materials was undertaken with Emily

Carr University of Art and Design, which included input from staff, patients and families.

Change of HH soap occurred. HH continues to be a regular topic for in-services and orientation.

High Achievers This Year: BC Cancer Agency – CN Radiation Therapy (100 per cent) BC Centre for Disease Control – STI Vancouver (95.5 per cent) BCCH – Sunny Hill (97 per cent) BCWH – Neonatal Intensive Care Unit (93 per cent ) Forensice Psychiatric Hospital – A2 (99 per cent ) Centre for Youth Mental Health – Child and Adolescent Psychiatric Emergency (94 per

cent )

Figure 1: The trend of PHSA overall HH compliance

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Cleaning, Disinfection and Sterilization

BC Children’s and BC Women’s floor cleaning equipment review In late 2014, the IPAC Service conducted a review of the floor cleaning procedures and cleaning equipment maintenance provided by Environmental Services in response to increased levels of dust and spores generated during floor cleaning on a closed unit during terminal cleaning. This review revealed a lack of procedures for cleaning and care of equipment. The IPAC Service made recommendations to Environmental Services on the use, maintenance and cleaning of floor cleaning equipment.

Since these recommendations were issued in November 2014, Environmental Services has developed cleaning and maintenance procedures and there are dedicated machines for patient care areas only to be used when patients are not present. Housekeeping Audits – BC Centre for Disease Control In February 2016 BCCDC contracted Westech Systems for routine housekeeping auditing at the Vancouver clinics (TB and STI) and the New Westminster TB clinic. Westech uses visual and ultraviolet (UV) markers to audit housekeeping practices, whereas prior to this only visual auditing was completed. The UV marker is applied to surfaces and is easily removed with normal cleaning. If cleaning was not done, the surface will show the mark under UV light. The first audit with Westech Systems was conducted in the Vancouver Clinics and New Westminster Clinic in March and April 2016, respectively. Visual audits showed an average score of 65 per cent and UV marker audits revealed a score of 16 per cent. Audit results are shared with the clinic leadership and WSI (housekeeping) leadership so that improvements can be made where necessary. Rapid DisinfectorTM Machine In January 2016, the IPAC Service, in collaboration with the Haematology/Oncology program and Environmental Services at BCCH, introduced the R-DTM Rapid DisinfectorTM (RD machine) to the inpatient and outpatient oncology units to target the reduction of C. difficile infections in this vulnerable population. The technology uses ultraviolet C light to disinfect the patient rooms, after regular cleaning, by killing microorganisms via disruption of DNA and RNA of viruses and drug-resistant bacteria, including C. difficile spores.

For the 6 month pilot implementation, the RD machine was used for all oncology inpatient discharge cleans as well as for the Oncology outpatient bathrooms and apheresis rooms. This pilot implementation included a survey for oncology unit staff and Environmental Services staff. Going forward, the plan is to establish a process that best utilizes the RD machine within the existing environmental

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services resources, with the goal of extending RD machine use to other areas of BCCH (e.g. operating rooms). Ministry of Health Audit Results The B.C. Ministry of Health (MOH) has mandated province-wide audits for reprocessing practices of critical and semi-critical medical devices since 2007. This was implemented using a standard audit tool to improve patient safety through adoption of http://www.health.gov.bc.ca/library/publications/year/2011/Best-practice-guidelines-cleaning.pdf

Table 3: PHSA medical device reprocessing compliance results (2010-2015).

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

Audit Section Description 2010 2011 2012 2013 2014 2015

Assessment & purchase of medical devices & reprocessing equipment

100% 100% 100% 100% 100% 100%

Environmental requirement for reprocessing area N/A N/A 92% 97% 96% 98%

Policies & procedures N/A N/A 100% 100% 100% 100%

Education & training 90% 99% 100% 100% 100% 100%

Occupational health & safety N/A N/A 91% 97% 100% 100%

Cleaning (decontamination) or reusable medical devices 96% 99% 100% 100% 99% 100%

Factors affecting product selection & efficacy of liquid chemicals

N/A N/A 100% 100% 100% 100%

Disinfection of reusable devices 92% 99% 100% 100% 100% 99%

Reprocessing endoscope devices N/A N/A 97% 100% 99% 99%

Sterilization of reusable medical devices N/A N/A 100% 100% 100% 100%

Storage & use of reprocessed medical devices N/A N/A 100% 100% 100% 97%

Quality assurance N/A N/A 100% 100% 100% 100%

Single use medical devices N/A N/A 100% 100% 100% 100%

Dental clinic (providing services to a health care facility) N/A N/A 67% 67% 67% 100%

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Construction Consultation The IPAC Service is actively involved in all construction, renovation and maintenance projects within PHSA to ensure that Canadian/provincial standards and best practices are considered and adhered to. Ongoing construction activities include:

o Collaboration with site multidisciplinary teams for planned construction and maintenance projects to ensure appropriate assessment of risk to the occupants of the facility.

o Approval, monitoring and documentation of preventative measures installed during construction projects to ensure effective barriers between patient/client and work areas.

o Consult on design during project planning phases (materials, work flow, sink and ABHR placement, etc.).

o Ongoing staff education on the risk of construction activities in healthcare facilities.

The Lower Mainland Facilities Management Infection Control Committee (LMFMICC) has a representative from the PHSA IPAC Service.

Major construction consultation activities during 2015-16 include: o Collaboration with the LMFMICC to develop an online training module for frontline Facility

Maintenance staff.

o Review of third party infection control and air monitoring activities during the construction of the Teck Acute Care Centre at BC Children’s.

o At BC Cancer Agency, the Centre for the Southern Interior chemotherapy and pharmacy department underwent a redesign in order to bring prep areas and mixing rooms up to current standards. The Vancouver Island Centre Pharmacy/Ambulatory Care Unit (ACU) re-design was intended to achieve compliance with the BC College of Pharmacists Standards. In addition, there was a need to improve space efficiency within the department given the increased workload since the department was designed. The first phase of this project involved the ACU re-design, followed by renovations of the third floor conference rooms to serve as a temporary pharmacy and finally, the third phase was the complete overhaul of the pharmacy. Another exciting project at Vancouver Island Centre this year was the installation of its first ‘Clean Room’ within the Deeley Research Center. This renovation was required to install specialized equipment for the manufacture of cellular therapy products as part of the Immunotherapy Program due to begin clinical trials in 2017.

o At FPH, the most significant construction project that impacted patient care was the Hawthorne House washroom rebuild. Omnicell renovations occurred on all units with minimal risk posed to patients and staff as all carpentry was performed off-site. All shower pans were replaced in Ashworth due to age; barriers reduced patient and staff exposure to construction dust.

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Surveillance In order to implement and evaluate interventions to reduce health care-associated infections (HAIs), PHSA IPAC conducts routine surveillance on all inpatients units at PHSA facilities. This section provides information on the incidence and trends of HAIs identified among patients admitted to three PHSA facilities (BC Children’s, BC Women’s and BC Cancer Agency - Vancouver Centre). Clostridium difficile Infection C. difficile is a spore-forming bacterium that can live in the intestines of healthy people. It may produce toxins and cause C. difficile infection (CDI), requiring prompt recognition, testing, and treatment. In 2015/16, 95 new CDI cases were identified. Thirty three (35 per cent ) of these were classified as health care-associated CDI (HA-CDI), corresponding to a rate of 6.4 cases per 10,000 inpatient days (Figure 4). At the facility level, zero cases were identified at BCWH. A slightly decreased HA-CDI rate was found for both BCCH and BCCA compared to 2014/15 (Figure 5). The rate of HA-CDI at PHSA is driven by oncology patients (26/33), who are at high risk for CDI due to frequent broad-spectrum antibiotic treatment and compromised immune systems. Given the complex nature of CDI, it is possible that some patients carried the organism in their intestines on admission without symptoms, rather than acquiring it in a health care facility. The IPAC Service has continually made efforts to prevent HA-CDI occurrence and minimize transmission through multidisciplinary collaborative work, including 1) hand hygiene promotion; 2) stringent environmental cleaning/disinfection, including implementation of a UV disinfection machine at BCCH/BCWH; 3) timely implementation of Contact Precautions for suspected and confirmed CDI patients; 4) audits using a CDI “tool kit” whenever there was a trigger alert.

Figure 4: Overall HA-CDI rate at PHSA acute care facilities

2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16PHSA HA-CDI rate 7.9 4.1 6.5 6.9 5.4 6.9 6.4

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Figure 5: HA- CDI rate by acute care facility at PHSA

Methicillin-Resistant Staphylococcus aureus Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that may colonize the skin and noses of healthy people but has the potential to cause infections with limited treatment options and life-threatening complications (e.g. pneumonia). In 2015/16, 80 new MRSA cases (including colonization and infection) were identified among patients admitted to PHSA facilities, 25 (31 per cent ) of which were classified as health care-associated MRSA (HA-MRSA). The PHSA HA-MRSA rate has increased since 2013/14, although the increase is not statistically significant (Figure 6). At the facility level, one HA-MRSA case was identified at BCCA in 2015/16. An increased rate of HA-MRSA was observed at both BC Children’s and BC Women’s. To prevent and control MRSA transmission, IPAC has initiated actions on targeted units with high MRSA burden, including implementation of MRSA screening compliance audits and reinforcement of appropriate hand hygiene practice.

Figure 6: Overall HA-MRSA rate at PHSA acute care facilities

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BCCA BCCH BCWHHA-CDI Rate 13.4 5.3 5.7 5.7 10.5 14.4 14.1 13.7 6.4 12.5 12.8 9.0 11.5 10.4 0.4 0.9 0.0 0.8 0.0 0.4 0.0

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HA-CDI incidence rate among inpatients at PHSA acute care facilities Ca

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2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16PHSA HA-MRSA Rate 0.9 1.7 2.0 2.0 1.0 2.3 2.9

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Figure 7: HA- MRSA rate by acute care facility at PHSA

Vancomycin-Resistant Enterococci Vancomycin-resistant enterococci (VRE) are bacteria that may colonize the intestines without causing symptoms. However some patients, particularly those with compromised immune systems or invasive devices, may develop VRE infections that are difficult to treat. In 2015/16, 34 new VRE colonization cases were identified at PHSA facilities, 16 (47 per cent ) of which were classified as health care-associated VRE (HA-VRE). Although the number is relatively small, the overall PHSA HA-VRE rate has increased since 2009/10 (Figure 8) across three PHSA facilities (Figure 9). Figure 8: Overall HA-VRE rate at PHSA acute care facilities

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BCCA BCCH BCWHHA_MRSA Rate 0.0 0.0 0.0 2.8 3.5 0.0 2.0 1.3 2.9 2.4 4.2 1.3 3.1 4.8 0.7 1.1 2.0 0.7 0.5 2.0 1.7

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2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16PHSA HA-VRE Rate 0.1 0.3 0.4 0.7 1.2 0.5 1.7

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Figure 9: HA-VRE rate by acute care facility at PHSA

Carbapenemase-Producing Organisms Carbapenemase-producing organisms (CPO) are gram-negative bacteria, such as E. coli and Klebisella species, that are resistant to almost all antibiotics. They are common in certain areas of the world but are spreading and have been found in British Columbia. Most people with CPO carry the bacteria in their gastrointestinal tract and do not have any symptoms. However, in some patients CPO can cause severe infections that are very difficult to treat. Surveillance for CPO began in 2012 at the BC Cancer Agency and 2014 at BC Children’s and BC Women’s. During 2015-16, no cases were identified at PHSA facilities. Catheter-Related Blood Stream Infection 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 (CVCs) to provide necessary vascular access. However, it also puts patients at risk for local and systemic complications, including catheter-related blood stream infection (CRBSI). Pediatric Intensive Care Unit at BC Children’s In 2015/16, three CRBSI cases were identified in PICU. The increase in CRBSI rate was not statically significant but merely reflects the small number of cases (three cases 2015/16 vs. one case in 2014/15).

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Figure 11: CRBSI rate at PICU unit at BCCH

Neonatal Intensive Care Unit at BC Women’s In 2015/16, an increased CRBSI rate was observed in NICU and the case number has increased to 29 cases from 13 cases last year. Figure 12: CRBSI rate at NICU unit at BC Children’s

Surgical Site Infections Infection following surgery can lead to prolonged hospitalization, increased patient anxiety and overall health care costs. Therefore, surgical site infections (SSI) surveillance has become a universal measure of quality in surgical programs. BC Children’s: The Department of Surgery joined the U.S.-based National Surgical Quality Improvement Program (NSQIP) in July 2011 to conduct pediatric SSI surveillance for selected surgical procedures, including post-discharge follow-up. Since then, IPAC at BC Children’s has been working closely with the NSQIP team on identifying issues and implementing measures to prevent SSIs.

2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16CRBSI rate 2.4 1.7 0.5 0.0 1.7 0.6 1.6

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CRBSI rate 6.7 3.0 3.3 4.8 5.2 4.2 2.4 5.0

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Incidence rate of CRBSI in Neonatal ICU at BCWH 2008/9 -2015/16

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BC Women’s: Annually, over 2,000 caesarean sections (C-sections) are performed at BC Women’s. Over the past few years, the IPAC Service has been working collaboratively with the Department of Obstetrics and Gynaecology to establish a reliable and sustainable C-section surveillance system. In February 2014, a pilot study was conducted by a research team at the hospital to test online patient reporting and a physician survey for collecting SSI information among patients who had C-sections. As a result, a new surveillance system was launched in January 2016, including a clinic designated to follow up patients who had C-sections at the hospital. Moving forward, IPAC will work closely with BC Women’s leadership and the research team to identify SSI issues in a timely manner. In 2015/16, based on IPAC C-section surveillance findings, 17 SSI cases were identified, including 12 superficial incisional and five organ space infections. Figure 13: C-section SSI cases identified at BC Women’s in 2015/16.

Tuberculosis at Forensic Psychiatric Hospital At Forensic Psychiatric Hospital surveillance for latent TB infection is conducted through tuberculin skin testing of compliant patients. In 2015-16, 78 patients had negative tests while there were 12 patients that required chest x-ray follow up for positive tests. Eleven of those were reported as normal, and one was suggestive of latent TB but the patient was not considered a good candidate for prophylactic treatment.

012345

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

2015 2016

# of

SSI

cas

es

C-section associated SSI case identifed at BCW

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Outbreak Management

Influenza Outbreaks: No influenza outbreaks were declared in any PHSA facilities in 2015/16. Gastroenteritis Outbreaks: Two laboratory confirmed norovirus outbreaks were declared at BC Children’s Hospital in 2015/16. The average length of these outbreaks was 9.5 days. A multidisciplinary approach was taken to manage the outbreaks. Key actions included isolation of suspect and confirmed patients, restriction of admissions and transfers, enhanced decluttering, cleaning and disinfection, suspending group activities, cohorting staff and cases, and visitor notification. In order to minimize interruption of patient flow, units were divided with a barrier to allow for patient admissions in special circumstances. Key concerns identified during outbreak debrief meetings: Lessons Learned: Actions Taken: Communication to all key stakeholders and frontline staff could be improved

• Creation of an outbreak communication distribution list to include all key stakeholders

Need for standardized procedure after hours

• Updating outbreak standards and developing an algorithm

• Creation of a Trigger Alert when there is increased gastroenteritis illness on a unit to prevent an outbreak from occurring

Need for an algorithm

Generic signage was not readily available

• Plans to create generic signage

Staff were not always ordering the correct lab test

• Investigating the use of a viral panel for stool testing to simplify ordering

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Projects and Initiatives PHSA

IPAC Perception Survey Between October 14 and November 7, 2015, the IPAC Service sent out an anonymous survey that targeted all PHSA employees, medical staff, and contracted providers (e.g. housekeeping, food services). The primary objective was to assess the perception of PHSA staff regarding IPAC services. IPAC received 668 responses, of which almost 80 per cent of responses were received from BCCA (n=228), BCCH (n=195) and BCWH (n= 107). Over half (59%) rated IPAC services in their workplaces as either good or excellent and satisfaction increased with frequency of IPAC contact (daily contact 69 per cent , weekly 64 per cent , monthly 60 per cent and yearly 55 per cent ). Awareness of IPAC information ranged from 17 per cent (annual report) to 96 per cent (hand hygiene information), but 71-88 per cent of those who had accessed the information found it useful. Further analysis and communication of survey results is underway, and the IPAC team is using the results to inform priorities and activities for 2016/17 and beyond. Audits Various audits have been conducted this year to ensure IPAC practices are being upheld at PHSA and to prepare the different sites for accreditation. Audits completed at BCCH and BCWH include the operating rooms, the milk bank, the Cardiac Outpatient Clinic and the Pharmacy Compounding Room. Audits have also begun for Antibiotic Resistant Organism (ARO) screening to assess compliance at BCCH and BCWH. Audits that have been conducted at BCCA include soiled utility rooms (VIC: which resulted in renovation for better separation of clean/dirty items, CN), pet therapy audits (VIC), cleaning practices in the high dose rate (HDR) brachytherapy suite (VC, FVC), IC practices in the HDR brachytherapy suite (VC, FVC), cleaning practices in nutrition (FVC), cleaning practices in radiation therapy (FVC, CN) and food service practices with volunteer services (FVC). BC Children’s and BC Women’s C. difficile study Investigators from the IPAC team, including Dr. Ghada Al-Rawahi (principal investigator), Dr. Simon Dobson and Dr. Peter Tilley, are currently working with oncology to study the prevalence of C. difficile colonization in pediatric oncology patients at admission to hospital and to determine the true rate of health care-associated C. difficile infection in pediatric oncology patients Invasive fungal infection study Investigators from the IPAC team, including Dr. Ghada Al-Rawahi (principal investigator), Sarah Wells, June Collet and Dr. Simon Dobson, are collaborating with oncology in a study to assess the potential impact of major hospital construction on Invasive Fungal Infection rates among high risk oncology patients, when risk-appropriate measures have been implemented.

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BC Cancer Agency Electronic health record documentation ICPs at BC Cancer Agency have begun the process of electronic documentation of complex consults to improve interdisciplinary communication and continuity of care. High Risk Infectious Disease (HRID) Response Plan Key stakeholders at BC Cancer Agency Vancouver Centre have recognized the usefulness of building on the West African Ebola Response plan to create a general High Risk Infectious Disease (HRID) Response plan. This plan was initiated at the Vancouver Centre and will soon be adapted to remaining cancer centres at BC Cancer Agency.

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Future Directions Moving forward, we aim to achieve our vision of empowering everyone to prevent infections. Our priorities for 2016-17 and beyond are aligned with our mission statement and include the following: A proactive approach to current and evolving challenges

• Promotion of frontline ownership (FLO) – One of the fundamental challenges in IPAC is achieving compliance with recommended practices, and organizational culture is a key factor. FLO is a culture change strategy based on the principle of bottom-up leadership and ownership from frontline staff. FLO seeks to target the way people interact with each other, which results in a change in group norms and organizational culture. IPAC team members across PHSA are starting to use elements of this approach, including facilitation tools known as Liberating Structures (www.liberatingstructures.com), in their interactions with staff. We are also working on a communications plan to get this message across to PHSA staff.

• Physician engagement– Physician engagement is fundamental to patient safety and quality care. IPAC will continue to engage PHSA physicians through residents’ orientation, IPAC presentations at division meetings/rounds, and regular communication of pertinent topics/updates.

Facilitating implementations and solutions

• Hand hygiene campaign refresh – The updated hand hygiene campaign will be rolled out across all PHSA agencies in 2016-17.

• Patient hand hygiene – There is increasing recognition that infections may be acquired by patients from the healthcare environment via their own hands, but there has been relatively little emphasis to date on patient hand hygiene compared to health care worker hand hygiene. We will start implementing pilot projects in 2016-17 to assess and improve patient hand hygiene at BC Children’s, BC Women’s and the BC Cancer Agency.

Expert consultation based on applicable regulations, evidence and best practice

• Accreditation – With BCCDC, Forensics, BC Children’s and BC Women’s undergoing Accreditation Canada surveys in 2016-17, the IPAC Service will play a key role in assessing and improving compliance with best practice standards. http://pod/HCQ/ACCREDITATION/pages/Default.aspx

• Audits – Team members at BC Children’s, BC Women’s and the BC Cancer Agency will continue to increase the number of audits being performed to assess compliance with best practice. For 2016-17 there will be a new Reprocessing & Audit Specialist to lead this initiative.

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• Infection control manuals – We will continue to improve the content and formatting and develop a revision cycle for the manuals across all sites.- http://bccwhcms.medworxx.com/Site_Published/bccwh/Home.aspx

• Construction – Major construction projects will be continuing and starting at BC Children’s, BC Women’s, the BC Cancer Agency and Forensic Hospital in 2016-17. Our Construction Specialist will continue to provide consultative services and improve the processes of communication and implementation of IPAC precautions.

Collaboration with local, provincial, and national partners

• Provincial signage – PHSA IPAC representatives worked with the PICNet Education Committee to develop standardized Additional Precautions signs for the entire province. These will be rolled out across PHSA in 2016-17. https://www.picnet.ca/

• Housekeeping – The role of environmental cleaning is crucial in IPAC. The IPAC Service will continue to work with Housekeeping staff to ensure that policies and procedures are in alignment with best practice guidelines.

• IPAC Canada Oncology Interest Group – As of January 2016,

the BCCA IPAC team has been working with IPAC Canada on planning activities to revitalize the IPAC-Canada Oncology Interest Group. While in its initial stages, the plan for the interest group is to engage IPAC groups across Canada, in examining current practices and making best practice recommendations for issues unique to Oncology. http://www.ipac-canada.org/

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Appendix A- PHSA IPAC Organizational Chart

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Appendix B 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. This includes:

o Cases identified for the first time during their hospital admission. o Cases identified previously at outpatient clinics but currently the patients being admitted

with positive VRE isolates. o Cases identified in the emergency department that are admitted subsequently (during

the same day).

This does NOT include:

o Cases identified in the emergency department but are not admitted. o Cases identified in outpatient clinics or other outpatient cases. o Case re-admitted with VRE.

Health care-associated VRE: A VRE case (as defined above) identified greater than 3 calendar days after admission, OR a VRE case identified 3 calendar days or less after admission, but is related to a previous admission within the last 12 months MRSA case: Laboratory confirmation of methicillin-resistant Staphylococcus aureus from specimens indicative of colonization or infection. This includes: o Cases identified for the first time during their hospital admission. o Cases identified previously at outpatient clinics but currently the patients being admitted

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

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

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

CDI case: 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 old). 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.

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Health care-associated CDI: A CDI case (including primary and relapse CDI cases) with symptom onset greater than 3 calendar days or more after admission, OR a CDI case with symptom onset in the community or 3 calendar days or less after admission, provided that symptom onset was less than 8 weeks after the last discharge. CPO case: Laboratory confirmation of carbapenem resistance/reduced susceptibility caused by a carbapenemase in specified Gram negative organisms, including Enterobacteriacae and Acinetobacter spp. Catheter-related bloodstream infection (CRBSI): A laboratory-confirmed bloodstream infection (BSI) where a catheter was in place for >2 calendar days on the date of the positive blood culture, with day of device placement being Day 1. Patient with BSI has met one of the following criteria:

o A recognized pathogen cultured from one or more blood cultures and unrelated to an infection at another site.

OR o At least one of: fever (>38°C), chills, hypotension (if aged < 1 yr: one of fever (> 38 °C),

hypothermia (< 36 °C), apnea, or bradycardia) AND infection signs and symptoms/ positive laboratory results are not related to an infection at another site AND common skin contaminant cultured from 2 or more blood cultures drawn on separate occasions.

Catheter includes:

• 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) • Implanted vascular access device (IVAD)

Gastrointestinal outbreak: Three or more cases of 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.

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 (counts are usually conducted at midnight) and multiplied by the number of days of hospitalization in a given time period.

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