INFECTION PREVENTION & CONTROL
&
ANNUAL REPORT
April 2012 – March 2013
Prepared by:
Provincial Health Services Authority Infection Prevention & Control (IPAC)
June 2013
Table of Contents
Message from the IPAC executive
3
1. About PHSA IPAC
5
2. Hand Hygiene Program – Stop the spread
8
3. Education
12
4. Reprocessing Practices
13
5. Surveillance
15
5.1. Cl ostridium difficile Infection
15
5.2. Methicillin – Resistant Staphylococcus Aureus
18
5.3. Vancomycin Resistant Enterococci
20
5.4. Catheter-Related Blood Stream Infecti on (CRBSI)
22
5.5. Surgical Site Infections (SSI)
24
5.6. Future directions of surveillance program at PHSA
25
6. Outbreak Management
26
7. Accreditation
27
Appendix A: Infection Prevention and Control Team
28
Appendix B: The patient service profile at PHSA facilities in 2012/13
29
Appendix C: Definitions
30
Message from the IPAC leadership team
Executive summary
Welcome to the Annual Report 2012/2013 of the Infection Prevention and Control (IPAC)
Service at the Provincial Health Service Authority (PHSA). In this report we describe the
progress of our activities during 2012/2013 in the areas of hand hygiene (HH), education,
reprocessing practices, surveillance and disease outbreaks.
Hand Hygiene (HH):
Our HH program, Stop the Spread, was initiated in 2008 and has gradually developed over the
years. IPAC is now performing regular HH audits across PHSA. The overall PHSA HH compliance
has increased from 40% in 2008 to 86% in 2012/13. This improvement includes all staff groups.
We attribute the success to an increased awareness, improved HH education, new social
marketing tools and public posting of individual ward HH compliance results. Physicians are
required to complete a HH module at the yearly privilege renewal process. We are continuously
monitoring the placement of alcohol based hand rub dispensers and monitoring their filling.
We expect to continue this positive trend and have representatives on the Provincial Hand
Hygiene Working Group.
Education:
Education is an essential component of the IPAC services. We provided 110 hours of infection
control (IC) education during 2012/13 to a total of 2029 attendees of various staff groups. We
encourage knowledge enhancement in our team and have been able to offer various learning
opportunities such as education conferences, seminars, web Tele classes and daily infectious
disease/infection control rounds.
Reprocessing of critical and semi critical items:
The PHSA reprocessing practices of critical and semi critical sterile supply items is audited
yearly. The audits conducted in 2012 showed 98% compliance. An external review of
reprocessing practices at BC Children’s Hospital (BCCH) and BC Women’s Hospital and Health
Centre (BCWH) was conducted in 2012. All recommendations have been addressed and a
permanent, multidisciplinary reprocessing committee composed of representatives from the
Operating Room (OR), Sterile Processing Department (SPD) and IC for BC Children’s Hospital
now meets regularly to address any SPD concerns in a timely manner.
Surveillance:
This report provides surveillance data for Clostridium difficile, MRSA and VRE rates as well as
catheter related blood stream infections in the Pediatric Intensive Care Unit (PICU) at BCCH and
the Neonatal Intensive Care Unit (NICU) at BCWH. We also provide limited surveillance data for
post surgical cesarean section infection rates.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 3 of 31
Indicator
PHSA Overall HH Compliance Rate
2011-12 Rate 2012-13 Rate
Progress
78%
85%
Improved
PHSA Overall HA – CDI Incidence Rate
6.9 per 10,000
inpatient days
7.3 per 10,000
inpatient days
Rate
Increased*
PHSA Overall HA – MRSA Incidence Rate
2.0 per 10,000
inpatient days
2.1 per 10,000
inpatient days
Rate
Increased*
PHSA Overall HA – VRE Incidence Rate
0.4 per 10,000
inpatient days
0.7 per 10,000
inpatient days
Rate
Increased*
Paediatric Intensive Care Unit CRBSI
Rate
0.5 per 1,000
catheter days
Zero
Rate
Decreased*
Neonatal Intensive Care Unit CRBSI Rate
4.8 per 1,000
catheter days
5.2 per 1,000
catheter days
Rate
Increased*
BC Cancer Vancouver Center CRBSI Rate
1.5 per 1,000
catheter days
Zero
Rate
Decreased*
*NOTE: Our overall HA case numbers are very small. None of the above rate changes are statistic ally significant.
The Health Associated-Clostridium difficle Infection (HA-CDI) rate at BCCA has remained low in
the past three years whereas our HA-CDI incidence rate overall is higher, but statistically
insignificant, at 13.9 cases/10,000 inpatient days. The majority of cases (75%) were found in
pediatric oncology patients, who have multiple risk factors for CDI, including immune
suppression and frequent antibiotic treatment. The IPAC service has reviewed HH practices,
housekeeping standards and a comprehensive audit of the oncology areas was conducted in
January 2013. This resulted in the formation of a multidisciplinary working group with
representation from nursing, IC, quality and infectious disease to address identified issues.
Three norovirus outbreaks occurred at PHSA – with 34 affected patients and 21 affected staff
members. All outbreaks were handled in conjunction with public health and resolved after 1826 days.
Accreditation:
During the week of June 19-22, 2012 Accreditation Canada surveyors visited BC Children’s and
BC Women’s Hospitals and both were awarded Exemplary Standing.
Eva Thomas
Corporate Director
PHSA Infection Prevention and Control
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 4 of 31
1. About PHSA Infection Prevention
& Control
At PHSA, the safety of patients, staff and visitors is of ultimate importance. To meet this
commitment, in 2006, a PHSA wide IPAC was formed, reporting to the PHSA VP of Quality and
Safety on all matters concerning infection control. The IPAC is working collaboratively with
other health authorities, Provincial Infection Control Network of B.C. (PICNet), regional and
national Public Health services in supporting best practice in infection prevention and control.
Our people:
The IPAC team consists of medical microbiologists, infectious disease physicia ns, infection
control professionals and one epidemiologist. The team collaborates with physicians, nurses
and other clinical staff as well as environmental health officers, medical health officers, public
health nurses and occupational health nurses and physicians.
Our mandate:
The IPAC is an essential component of patients’ quality of care. The IPAC’s goal is to ensure the
protection of patients, health care workers, staff and visitors from preventable healthcare
associated disease and to achieve that prevention in a cost-effective manner.
Our services:
The IPAC delivers comprehensive infection prevention and control services to its stakeholders
in a constructive and collaborative manner through education, surveillance, consultation,
outbreak investigation, research and the development of policies and procedures.
Education
The IPAC provides education to staff, patients and visitors about the best practices for infection
prevention and control. The IPAC is constantly assessing, developing and revising strategies to
ensure that the learning outcome is optimal.
Surveillance
To reduce the risk of disease transmission in the hospital, the IPAC conducts surveillance during
daily ward rounds and/or by checking microbiology laboratory significant findings.
The IPAC team use the surveillance data to:
o Determine the burden of specific infectious diseases at PHSA facilities .
o Monitor incidence and trends of specific infectious diseases identified at PHSA facilities.
o Detect infectious cases so that appropriate control measures can be implemented.
o Detect clusters of infectious disease and manage outbreaks.
o Evaluate interventional strategies.
o Meet various quality and safety indicator reporting obligations.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 5 of 31
Outbreak management
The IPAC is responsible, in collaboration with public health, for the investigating clusters of
infection cases and declaring outbreaks at any of the PHSA facilities as appropriate.
Standardized control measures are promptly implemented when an outbreak is declared.
Sterilization and reprocessing practices
Working closely with the sterilization and reprocessing department (SPD), the IPAC ensure the
PHSA agencies deliver a safe, high quality medical device reprocessing practice. The IPAC is
responsible for:
o
o
o
o
o
Providing advice based on best available evidence and Canadian/provincial standards.
Providing the education, training, and competency assessment of reprocessing staff.
Developing ongoing quality assurance planning, risk assessment and remediation based
on Best Practice Guidelines.
Conducting ongoing monitoring and halt activities known to be inconsistent with best
practices (e.g., reprocessing of "in-house" manufactured devices).
Submitting the audit reports and other required materials to the Ministry on an
ongoing basis.
Construction consultation
The IPAC is actively involved in infection prevention and control issues relating to all
construction and renovation projects within PHSA to ensure that IPAC standards are considered
and adhered to. The IPAC has representation on the Lower Mainland Facilities Management
Infection Control Committee (LMFMICC).
Our facilities:
The IPAC team provides infection prevention and control services to 13 sites within PHSA
located in the following communities:
o BC Center of Disease Control – Vancouver
o BC Center for Disease Control – New Westminster
o BC Children’s Hospital - Vancouver
o Sunny Hill Health Center for Children - Vancouver
o BC Women’s Hospital & Health Centre - Vancouver
o BC Mental Health & Addiction Services ( Children) - Vancouver
o BC Mental Health & Addiction Services( Forensic) – Port Coquitlam
o BC Cancer Agency - Vancouver Center
o BC Cancer Agency – Abbotsford Centre
o BC Cancer Agency – Fraser Valley Centre - Surrey
o BC Cancer Agency – Vancouver Island Centre - Victoria
o BC Cancer Agency – Centre for the North - Prince George
o BC Cancer Agency – Cindy Sindi Ahluwalia Hawkins Center for the Southern Interior Kelowna
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 6 of 31
BC Centre for Disease Control
New Westminster Clinic
BC Centre for Disease Control
Vancouver Clinic
BC Children’s Hospital
BC Children’s Mental Health
Sunny Hill Health Centre for
Children
BC Women’s Hospital
BC Cancer Agency
Vancouver Centre
BC Cancer Agency
Vancouver Island Centre
BC Cancer Agency
Abbotsford Centre
BC Cancer Agency
Centre for the Southern
Interior
BC Cancer Agency
Centre for the North
BC Women’s Hospital
BC Cancer Agency
Fraser Valley Centre
Patients first.
Forensic Psychiatric Services
Results matter.
Best value.
Excellence through knowledge.
Page 7 of 31
2. Hand Hygiene Program – Stop the spread
Led by IPAC, the PHSA Hand Hygiene (HH)
program was developed, based on the
concepts and materials recommended by
WHO’s Global "Clean Care is Safer Care". These
are similar to the HH component of “Safer
Health Care Now” a national patient safety
program of Canadian Patient Safety Institute.
A comprehensive HH program – Stop the
Spread – was initiated in 2008 and is now
implemented in all PHSA agencies.
Over the last few years, the IPAC team has been busy evaluating and improving our HH
program. Many new social marketing tools and strategies have been launched. Examples
include “Its’ OK to ask” posters, lanyards, banners and a revised HH video. Education sessions
regularly occur throughout the entire organization and are well received by various audiences.
Major HH activities 2012-13 include:
o Performed regular HH audits across all PHSA sites.
o Added new sites/departments to the audit process
including BCCA Centre for the North.
o Celebrated World HH Day in May at all sites - using
stickers, posters, banners, roving carts, prizes and
games.
o Celebrated National Infection Control Week in
October.
o Provided regular in-services, orientation.
o Provided regular updates of the BCCH intranet HH
team site.
o Distributed HH lanyards with Stop the Spread Wash
your hands- PHSA wide.
o Used HH Banners for all sites and prominently
displaying them during the national IC week and
World HH Day.
o Installed and reviewed the location of alcohol based
hand rub dispensers.
Patients first.
Results matter.
Best value.
Roadshow cart, in-patient unit, C&W
Excellence through knowledge.
Page 8 of 31
There are a total of 45 units/services at PHSA, which are audited quarterly or semi -annually for
HH compliance by trained auditors. The HH auditors observe a sample of staff working at all
sites within PHSA. The results are posted in public spaces on each unit. Audited staff include:
nurses, physicians, clinical support services and others such as housekeeping staff.
Our achievements:
o Overall, the PHSA HH compliance has increased from 40% in 2008/09 to 86% in Q4
2012/13. The provincial HH performance target of 80%, set for the end of 2014/15, was
met. (Figure 1).
o A sustained improvement in HH compliance was seen across all PHSA agencies (Table 1).
o Comparing data from two fiscal years (2010/2011 vs. 2011/12), there is an overall
improvement of HH compliance in all Healthcare provider (HCP) groups, including
physicians (Figure 2).
o In July 2012, an audit of the alcohol based hand sanitizer dispersers used at all PHSA
agencies (exclusive of the BC Cancer Centre located in Kelowna and two BCCDC sites) was
conducted. The result showed that overall HH product availability at PHSA was high at
97%. (Figure 3).
Figure 1: PHSA Overall HH by Fiscal year and Quarter
The Trend of PHSA Overall HH Compliance
2008/09 - 2012/13
100%
80%
60%
40%
20%
0%
Total HH opportunities
Q2
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2008/09
2009/10
2010/11
2011/12
2012/13
1209 3139 1433 1335 1274 1278 718 723 236 886 1469 1350 1416 1948 3384 1672 3436 1631 2550
Number of HH compliance
520 1549 826 822 849 688 502 444 138 596 1097 1026 995 1605 2723 1346 2706 1355 2198
PHSA overall compliance percentage 43% 49% 58% 62% 67% 54% 70% 61% 58% 67% 75% 76% 70% 82% 80% 81% 79% 83% 86%
Provincial HH performance target
Patients first.
80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%
Results matter.
Best value.
Excellence through knowledge.
Page 9 of 31
Marney Hunt, Infection Control (far right) and C&W staff show their hands in support of STOP! Clean Your Hands Day at the
Crossroads interactive station, BC Children’s & BC Women’s site
Table 1: Institution specific overall HH Compliance
Facility
BC Children’s
Sunny Hill Health Center for Children
BC Mental Health– Children
BC Women’s
BC Cancer Agency
BC Centre for Disease Control
BC Mental Health – Forensics
PHSA overall
Apr - Jun
76%
86%
81%
80%
80%
93%
80%
2012/13 HH Compliance
2012
Jul -Sep
Oct -Dec
72%
87%
90%
83%
69%
76%
83%
78%
75%
95%
79%
83%
2013
Jan - Mar
92%
94%
86%
87%
83%
82%
94%
86%
- : No HH observation done for this period.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 10 of 31
Figure 2: PHSA HH Compliance at Acute Care Facilities by Healthcare Provider (HCP)
HH compliance by HCP Group
100%
80%
60%
40%
20%
0%
Nursing Staff
Physicians
Clinical Support
Services
Other
2011/12 Compliance
79%
67%
62%
64%
2012/13 Compliance
81%
74%
78%
72%
Figure 3: Alcohol Based Hand Sanitizer (ABHS) Dispenser Audit by Facility/Agency
Alcohol Based Hand Sanitizer (ABHS) Dispernser Product Availability
Audit done at PHSA on July 16-18. 2012
100%
% product availablity
80%
60%
40%
20%
0%
BCCA
Abbotsford
BCCA Fraser
Valley
BCCA
Victoria
Forensics
BCCA
Vancouver
BCCH
BCWH
Dispenser Broken
0%
0%
0%
0%
0%
1%
0%
Dispenser Empty
8%
7%
6%
5%
3%
1%
1%
Dispenser Full
92%
93%
94%
95%
97%
97%
99%
Patients first.
Dispenser Broken
Dispenser Empty
Results matter.
Best value.
Dispenser Full
Excellence through knowledge.
Page 11 of 31
3. Education
Education is an essential component of the IPAC services. The IPAC delivers education sessions
to all new employees during orientation, and provides ongoing in-service and just-in-time
consultation for all PHSA staff. On a daily basis, the infection control professionals (ICPs)
address patient-, procedure-, or unit-specific concerns through phone consultation, regular
ward visits and ICP rounds.
The IPAC team is constantly developing, assessing and revising education material and
strategies to meet the staff’s learning needs related to best practices of infection control.
Various education resources, such as information brochures, infection control “hot topic”
flyers, and results from current research are developed and disseminated to PHSA staff on a
regular basis. The Infection Prevention and Control Basic course, Hand Hygiene for Medical
Staff, and the Provincial HH Module are available online for all staff through the PHSA Learning
Hub.
In 2012/13, a revised infection control manual, which incorporates the current best practice of
infection control, was successfully launched at BCCH, BCWH and BCCA. To facilitate the use and
adaptation of the new manuals, the IPAC developed an online version of the manuals and made
them readily accessible to all PHSA staff via the agency’s intranet.
In summary, in 2012/13 the IPAC team delivered over 110 hours of education sessions, reaching
over 2029 staff (Table 1).
Table 2: Education Actives Provided by IPAC in 2012/13.
Education Type
New Employee Orientation
Reprocessing of Medical Devices
Antibiotic Resistant Organisms
Hand Hygiene
General infection control
Transmission-based precautions
Infection Control Manual Launch
Other
Total
# of attendees
815
50
30
532
229
169
154
50
2029
Estimated Hours
32
36
2
17
7
5.5
10
1
110.5
The IPAC leaders also encourage the IPAC members’ self led development and knowledge
enhancement. The IPAC has continually offered the team members various learning
opportunities such as attending national/international infection control education conferences,
educational days (i.e. PICNet, CHICA-BC), the Canadian Standards Association (CSA) seminars,
web Teleclasses, Infectious Diseases/Medical Microbiology rounds and Oncology rounds. Thus,
the IPAC members are up to date with current infection control best practices.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 12 of 31
4. Reprocessing Practices
In 2007, The B.C. Ministry of Health (MOH) instituted the first province wide audits for the
reprocessing of critical and semi-critical devices. The MOH audits are designed to improve
patient safety through adoption of best practices guidelines for cleaning, disinfection and
sterilization of medical devices in BC Health Authorities. The audits are mandatory and required
to be done annually, using an audit tool prepared by the MOH.
The audits conducted in 2012 have shown that overall PHSA medical device reprocessing
compliance has improved from last year 97% to 98% this year.
Table 3: PHSA Medical Device Reprocessing Compliance Results (2007-2012).
Item
Audit Section Description
2007 2009 2010 2011 2012
1
Purchasing & reprocessing instruction
53%
98%
100%
100%
100%
2
Environmental requirement for reprocessing area
N/A
N/A
N/A
N/A
92%
3
Policies & procedures
N/A
N/A
N/A
N/A
100%
4
Education
67%
55%
90%
99%
100%
5
Occupational health & safety
N/A
N/A
N/A
N/A
90%
6
Cleaning or reusable medical devices
78%
79%
96%
99%
99%
7
Factors affecting product selection & efficacy of liquid chemicals
N/A
N/A
N/A
N/A
100%
8
Chemical HLD, no endoscopes / disinfection of reusable devices
58%
69%
92%
99%
99%
8a
Documentation (disinfection of reusable medical devices)
N/A
19%
89%
95%
100%
8b
Pasteurization (Thermal disinfection)
97%
100% 100%
100%
100%
9
HLD flexible endoscope
83%
85%
92%
100%
98%
9a
Reprocessing endoscope devices -- disinfectant
N/A
N/A
N/A
N/A
100%
9b
HLD automated disinfection (AER)
90%
97%
100%
100%
97%
9c
Endoscope storage
54%
53%
73%
98%
88%
9e
Documentation (HLD flexible endoscope)
76%
56%
96%
98%
100%
Note: N/A indicates that this activity is not performed.
* Dental clinic cannot meet the environmental requirement session due to the current space restriction.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 13 of 31
Major sterile processing activities performed at PHSA facilities for the fiscal year
include:
o Completion of the fifth MOH mandated reprocessing audit.
o Review of appropriate location for reprocessing of flexible scopes.
o Collaboration between BCCH and BCWH Sterile Processing, the OR suite & Infection
Control to address any potential reprocessing challenges
o Completion of the recommendations resulting from reports of External Review of
Reprocessing Practices and Failure Models Effects Analysis conducted by Quality, Safety
and Outcome Improvement.
o Provision of clinical resources in support of teaching program – Vancouver Community
College Sterile Processing Technician Certificate program.
o Completion of a reprocessing review of flexible scopes at BCCA -- Terrace and Centre of
North.
o Provision of ongoing staff education across PHSA.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 14 of 31
5. Surveillance
Healthcare associated infections (HAIs) are associated with prolonged hospitalization, increased
patient morbidity and healthcare costs. PHSA routinely measures rates of Clostridium difficile
Infection (CDI), methicillin resistant staphylococci (MRSA), vancomycin resistant enterococci
(VRE) and catheter-related infections in all patients admitted to acute care facilities at PHSA
(i.e. BCCH, BCWH and BCCA). This ongoing surveillance effort enables IPAC to make informed
decisions, implement effective policies and develop guidelines to address infection prevention
issues. This section provides information on the incidence and trend of each measure over the
last four years as well as pertinent action plans based on the surveillance findings.
5.1. Clostridium difficile Infection
Clostridium difficile (C.diff) is a spore forming bacterium that is commonly found in the
environment and can live in the intestines of healthy people. C.diff may produce toxins and
cause C.diff infection (CDI). CDI can present as mild diarrhea, but occasionally progresses to a
severe infection resulting in serious complications such as bowel perforation, toxic megacolon,
sepsis and even death. CDI is considered a quintessential antibiotic-driven disease. Antibiotics
can change the normal balance of “good” and “bad” bacteria in the intestines. If the number of
“good” bacteria decreases C.diff may grow out of control. Additional risk factors for CDI include:
prolonged hospitalization, inflammatory bowel disease, solid organ transplantation, gastric acid
suppression, chemotherapy/immunosuppression and presence of a gastrostomy tube. Key to
controlling CDI is the prompt recognition, testing, and treatment of patients with CDI. The
primary way of C.diff transmission is person-to-person spread through the fecal-oral route. The
use of contact precautions is currently recommended for those recognized as having CDI.
In 2012/13, a total of 93 CDI cases were identified in the different PHSA facilities; forty (48 %) of
which were classified as healthcare associated CDI (HA-CDI).
o 34/40 cases were identified at BCCH;
o 4/40 cases at BCCA;
o and 2/40 cases at BCWH.
Twenty-seven of 34 (80%) of the HA-CDI cases at BCCH were paediatric oncology patients,
who are at high risk for CDI due to frequent broad-spectrum antibiotic treatment and
immune compromise. Hence, the rate of HA-CDI at PHSA is driven by paediatric oncology
patients. While the CDI cases meet the surveillance definition of “HA-CDI” (see appendix II),
it does not mean that these cases are transmitted between patients in the hospital. Given
the complex nature of CDI development, it is possible that some patients carry the C.diff
organism in their intestines without presenting diarrhea; then the antibiotic treatment
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 15 of 31
alters the normal intestines flora and the endogenous C.diff thrive, causing infection.
Figure 4: The overall PHSA HA –CDI rate in the fiscal year (FY) 2012/13 is 7.3 cases per 10,000
inpatient days (95% CI: 5.4-9.9). This overall rate represents a slight increase from the rate of
6.9 (95% CI: 5.1-9.5) in 2011/12 but is not statistically significant. The incidence rate of HA-CDI
remains low at BCWH. Both BCCH and BCCA experienced a drop of HA - CDI rate in 2010/11.
The HA-CDI rate at BCCA has remained low in the past three years. At BCCH the HA-CDI rate
increased in 2010/11 and is at 13.9 cases per 10,000 patients in 2012/13 (Figure 5).
Fi gure 4: Overal l PHSA i nci dence rate of HA- CDI at acute care faci l i ti es
Cases per 10000 inpatient days
PHSA overall incidence rate of HA -CDI
2009/10 -2012/13
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
PHSA HA-CDI rate (with 95% CI)
2009/1
0
2010/1
1
2011/1
2
2012/1
3
7.9
4.1
6.9
7.3
Note:
1. Patients in psychiatric beds or less than one year of age were excluded in the calculation of rates.
2. Starting November 2011, PCR testing for CDI has been introduced at C&W. This more sensitive labora tory
test may detect more CDI cases compared to the use of previous laboratory tests.
Figure 5: Incidence rate of HA- CDI by acute care facilities
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 16 of 31
Cases per 10000 inpatient days
Incidence rate of HA-CDI by acute care facilities at PHSA
30.0
25.0
20.0
15.0
10.0
5.0
0.0
2009 2010 2011 2012
/10 /11 /12 /12
2009 2010 2011 2012
/10 /11 /12 /12
BCCA
Incidence rate of HA-CDI (with 95% CI) 13.4
5.3
5.7
2009 2010 2011 2012
/10 /11 /12 /13
BCCH
5.7
13.7
6.4
13.4
BCWH
13.9
0.4
0.9
0.0
0.9
In response to the high HA-CDI rate at BCCH, the following measures have been implemented
by PHSA IPAC to prevent CDI occurrence and minimize the spread of infection:
o Continuing hand hygiene promotion.
o Stringent environmental cleaning/disinfection.
o Close monitoring for signs of transmission among patients.
o Rapid implementation of infection control measures at the first sign of symptoms.
o Increased staff education re. hand hygiene and housekeeping standards.
o An audit of infection control and housekeeping standards on the oncology wards was
performed in January of 2013.
o As a result of this audit a BCCH multidisciplinary working group, involving all key
stakeholders, was formed. This working group meets regularly to address all identified
issues.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 17 of 31
5.2. Methicillin – Resistant Staphylococcus Aureus
Staphylococcus aureus (Staph) is a type of bacterium that is commonly found on the skin and in
the nose of healthy people. At any given time, between 20 and 30 per cent of the general
population carry Staph bacteria on their hands or in their nose, but are not ill. Staph bacteria
that are resistant to the antibiotic methicillin are known as Methicillin-resistant Staphylococcus
aureus (MRSA). MRSA has the potential to cause infections for which treatment options are
limited. If left untreated, MRSA infections may develop into serious, life-threatening
complications such as infection of the bloodstream, bones and/or lungs (e.g., pneumonia).
MRSA is usually spread through direct physical contact or through contact with objects
contaminated with infected body fluids. Bacteria on hands can spread to others if good hand
hygiene is not performed. People with weakened immune systems and chronic conditions may
be more susceptible to the infection.
In 2012/13, 20 patients across PHSA were classified as having Healthcare associated MRSA (HAMRSA) [14/20 cases were identified at BCCH, 4/20 cases at BCCA and 2/40 cases at BCCA].
Fourteen of the 20 cases were identified through our routine hospital screening program.
Three of the 20 cases had a blood stream infection, two had MRSA in their urine and one had
an MSRA wound infection.
The high proportion of HA-MRSA cases identified through routine screening highlights the
importance of such screening programs. This allows for the early detection of MRSA carriers so
that control measures can be implemented in a timely manner.
The overall PHSA HA-MRSA rate remains stable in 2012/2013 [(2.1 cases per 10,000 patient
days (95% confidence interval (CI): 1.4-3.2)].
Figure 6: Overal l PHSA i nci dence rate of HA-MRSA at acute care faci l i ti es
PHSA overall incidence rate of HA -MRSA
2009/10 -2012/13
Cases per 10000 inpatient days
10.0
8.0
6.0
4.0
2.0
0.0
PHSA HA-MRSA rate (with 95% CI)
Patients first.
2009/10
2010/11
2011/12
2012/13
0.9
1.7
2.0
2.1
Results matter.
Best value.
Excellence through knowledge.
Page 18 of 31
The rate of HA - MRSA varied greatly by facilities. At BCWH, the rate was lower in FY 2012/13.
Both BCCH and BCCA reported a slightly higher HA-MRSA rate this year. None of these
differences were statically significant.
Fi gure 7: Incidence rate of HA- MRSA by acute care facilities
Cases per 10000 inpatient days
Incidence rate of HA-MRSA by acute care facilities at PHSA
20.0
15.0
10.0
5.0
0.0
2009
/10
2010
/11
2011
/12
2012
/12
2009
/10
2010
/11
BCCA
Incidence rate of HA-MRSA (with 95% CI)
Patients first.
0.0
0.0
Results matter.
0.0
2011
/12
2012
/12
2009
/10
BCCH
2.8
1.3
Best value.
2.9
2.4
2010
/11
2011
/12
2012
/13
BCWH
4.4
0.7
1.1
2.0
0.7
Excellence through knowledge.
Page 19 of 31
5.3. Vancomycin Resistant Enterococci
Enterococci are bacteria that live in our intestines and on our skin, usually without causing
problems. Vancomycin-resistant enterococci (VRE) refer to certain stains of enterococci that
have developed resistance to Vancomycin and often other antibiotics, making them difficult to
treat.
A person could be colonized with VRE without having symptoms of illness. However, VRE may
cause infections. These can occur anywhere in the body. Some common sites include the
urinary tract and wounds. For some people, especially those who are weak or ill, these
infections can become serious.
VRE, like many bacteria, can spread from patient to patient when bacteria are carried on the
hands of healthcare workers and occasionally through contact with contaminated equipment or
other surfaces (e.g. toilet seats, bedrails, door handles, soiled linens, stethoscopes etc). This is
why proper infection prevention and control practices, such as good hand hygiene and the use
of personal protective equipment such as gloves are important in hospital settings.
VRE infections occur most commonly in healthcare settings among patients with weakened
immune systems. Those who have been previously treated with vancomycin or other antibiotics
for long periods of time; those who have undergone surgical procedures and those with
medical devices such as urinary catheters are at a higher risk of becoming infected with VRE.
In 2012/13, 15 new cases of VRE were identified in two PHSA facilities. Seven of 15 (47 %) were
classified as HA-VRE (4/7 identified at BCCA and 3/7 at BCCH), corresponding to an overall PHSA
HA–VRE rate of 0.7 cases per 10,000 inpatient days (95% CI: 0.4-1.5). None of these had clinical
symptoms but were colonised.
The overall PHSA HA – VRE rate in FY 2012/13 is 0.7 cases per 10,000 inpatient days (95% CI:
0.4-1.5). This represents a slight rate increase but it is not statistically significant.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 20 of 31
Figure 8: Overal l i nci dence rate of HA-VRE at acute care faci l i ti es at PHSA
PHSA overall incidence rate of HA -VRE
2009/10 -2012/13
Cases per 10000 inpatient days
10.0
8.0
6.0
4.0
2.0
0.0
2009/10
2010/11
2011/12
2012/13
0.1
0.3
0.4
0.7
PHSA HA-VRE rate (with 95% CI)
Fi gure 9: Incidence rate of HA- VRE by acute care facilities
Cases per 10000 inpatient days
Incidence rate of HA-VRE by acute care facilities at PHSA
25.0
20.0
15.0
10.0
5.0
0.0
2009
/10
2010
/11
1.3
1.3
2011
/12
2012
/12
2009
/10
2010
/11
5.7
0.0
0.6
BCCA
Incidence Rate of HA-VRE (with 95% CI)
Patients first.
Results matter.
0.0
2011
/12
2012
/12
2009
/10
2010
/11
1.0
0.0
0.0
BCCH
Best value.
1.2
2011
/12
2012
/13
BCWH
0.0
0.0
Excellence through knowledge.
Page 21 of 31
5.4. Catheter-Related Blood Stream Infection (CRBSI)
Central venous catheters (CVC) are indispensable in modern-day medical practice, particularly
in the care of patients with severe illness such as those in intensive care units (ICUs). Although
such catheters provide necessary vascular access, their use puts patients at risk for local and
systemic infectious complications, including local site infection, catheter related blood stream
infection (CRBSI), septic thrombophlebitis, endocarditis, and other infections (e.g., lung abscess,
brain abscess, osteomyelitis, and endophthalmitis).
Potential risk factors for CRBSI include underlying disease, method of catheter insertion, the
type of catheter used, catheter insertion site, duration and frequency of manipulation. ICU and
oncology patients are particularly vulnerable to CRBSI. In the ICU, a CVC might be needed for
extended periods of time; patients can be colonized with hospital-acquired organisms; and the
catheter may be accessed multiple times per day for the administration of fluids, drugs, and
blood products, increasing the potential for contamination and subsequent clinical infection
PHSA agencies deliver highly specialized care in high risk areas such as oncology, neonatal and
paediatric intensive care units. Many of the patients in these units have central venous
catheters and therefore, conducting surveillance of CRBSI in these high risk patients group is a
pivotal component of the IPAC.
BCCA - Vancouver Centre
Collection of CRBSI data began in September 2011 following the implementation of a consistent
denominator collection method (CVC days). In 2012/13, at BCCA 480 CVC days were recorded.
No cases of CRBSI were identified during this period.
Paediatric intensive care unit at BCCH
In 2012/13, there were no CRBSI cases identified at the paediatric intensive care unit (PICU).
Cases per 1000 catheter days
Incidence rate of CR-BSI in Pediatric ICU at BCCH
10.0
8.0
6.0
4.0
2.0
0.0
CR-BSI Rate
Patients first.
2009/10
2010/11
2011/12
2012/13
2.4
1.7
0.5
0.0
Results matter.
Best value.
Excellence through knowledge.
Page 22 of 31
Neonatal intensive care unit (NICU) at BCWH
In 2012/13, 28 CRBSI cases were identified at the neonatal intensive care unit (NICU),
corresponding to an incidence rate of 5.2 cases/1000 catheter days. The rate has increased
slightly compared to previous years, but the increase is not statistically significant. We continue
to monitor each incident and the rate closely.
Cases per 1000 catheter days
Incidence rate of CR-BSI in Neonatal ICU at BCWH
10.0
8.0
6.0
4.0
2.0
0.0
CR-BSI Rate
Patients first.
2009/10
2010/11
2011/12
2012/13
3.0
3.3
4.8
5.2
Results matter.
Best value.
Excellence through knowledge.
Page 23 of 31
5.5. Surgical Site Infections (SSI)
Infection following surgery can lead to serious complications including prolonged
hospitalization, increase patient anxiety and overall health care costs. Therefore, SSI
surveillance has become a universal measure of quality in surgical programs .
BCCH: In July 2011, the Department of Surgery at BCCH joined the U.S based National Surgical
Quality Improvement Program (NSQIP) and began conducting a pediatric SSI surveillance,
including post discharge follow-up. This was implemented for selected procedures only.
To avoid the duplication of surveillance efforts, the PHSA IPAC Service has been working with
the Department of Surgery and the NSQIP team to identify appropriate IPAC surgical site
surveillance initiatives. As cardiac surgeries are not part of the NSQIP program, the IPAC Service
is in the process of exploring an SSI surveillance system for these surgeries.
BCWH: Over 2000 Caesarean Sections (C-section) are performed at BCWH annually. Until 2010,
surveillance on SSI associated with C-section at PHSA was restricted to patients who developed
SSI during their post-operation hospital stay or who were readmitted as a result of SSI.
Over the past few years, the IPAC team has been working with the Department of Obstetrics
and Gynaecology and Providence Health Care (PHC) on developing standardized definitions,
surveillance tools and SSI case finding methods for C-section. Between November 2011 and
April 2012, PHSA IPAC conducted a pilot study to test the practicality of these tools and assess
the impact of a new enhanced SSI case finding method.
In October 2012, the IPAC resumed the C-section surveillance by using a mixed method (i.e.
improved in-patient surveillance and a post discharge chart review at 30 days for C-sections
performed every Monday). Nine SSI cases were identified throughout the course of the fiscal
year. Seven of nine cases developed SSI during the post operation hospital stay. The other two
cases were developed post-discharge.
Figure 12. BCWH C-section SSI Rate
C-section SSI Incidence Rate at BCWH
6.0%
4.0%
2.0%
No enhanced surveillance
0.0%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
2012
# SSI
1
C-section procedures
164
159
175
185
193
174
Rate per 100 C-section 0.6%
Patients first.
Results matter.
Feb
Mar
2013
Best value.
2
2
2
1
1
0
210
204
176
177
158
156
1.0%
1.0%
1.1%
0.6%
0.6%
0.0%
Excellence through knowledge.
Page 24 of 31
5.6. Future directions of surveillance programs at PHSA
Over the past few years, the IPAC team has been focusing on the development of a sustainable
and effective surveillance system. This effort has led to several surveillance programs being
successfully implemented at PHSA, including surveillance of MRSA, VRE, CDI and CRBSI.
The IPAC regularly reviews the surveillance program’s goals and processes to ensure that the
program meets the needs of the institutions in context of high data quality and system
efficiency. Led by the IPAC senior leadership team and epidemiologist, the surveillance process
is reviewed annually to ensure that the definitions are relevant and accurate, and the data
collection process is balanced between being comprehensive and efficient.
Increasingly, the IPAC executive team has recognized the need of building a system for
expanding the surveillance scope to address new HAI risks in a changing environment. Future
surveillance targets may include new high-risk medical or surgical interventions, some new
pathogens and their resistance to antibiotics, and other emerging problems.
Quality improvement is now a driving force in healthcare. The commonly used improvement
approach “PDSA” (Plan-Do-Study-Act) cycle requires precise measurement of specific indicators
(1) to identify and quantify problems and (2) to assess whether we have in fact achieved
improvement. Surveillance data is therefore a vital resource which enables us to accurately
identify problems and prioritize improvement initiatives.
Moving forward, the IPAC is putting effort into developing a timely data feedback mechanism
and improving its data communication with all stakeholders, especially the front-line staff. The
collection and analysis of surveillance data will be performed in context of a prevention
strategy. In addition, the IPAC will continue to support excellence in patient care by meeting
various reporting obligations, including PHSA performance measurement as well as provincial
and national benchmark reporting. The IPAC will continue to participate and support the
provincial program PICNet and the Canadian Nosocomial Infection Surveillance Program (CNISP)
by providing evidence-based data that can be used to establish benchmarks, identify trends to
develop provincial/national guidelines to help reduce the transmission of Healthcare Associated
infections (HAI).
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 25 of 31
6. Outbreak Management
Outbreaks are defined as a localized increase (e.g. in a unit, in a hospital) of the occurrence of
an event (e.g. disease) over expected numbers. A small rise in events may be referred to as a
“cluster”. Both “clusters” and “outbreaks” require prompt investigation and management. To
identify an outbreak, baseline endemic rates must be available for comparison.
Outbreaks may occur for a number of reasons such as for example the introduction of and
transmission of an infectious disease within the healthcare site, lapses in infection control
practices, contaminated or defective products or devices . While outbreaks will continue to
occur, many can be prevented or have reduced impact through intentional, knowledgeable and
rapid management practices.
The primary IPAC safety goal is to decrease the occurrence and duration of outbreaks in PHSA.
Routine surveillance allows IPAC for the early detection of clusters so that the appropriate
interventions can be implemented swiftly to limit transmission. Once an outbreak identified,
IPAC facilitates immediate and concurrent involvement of all areas impacted by an outbreak.
A Risk-Based Model remains the central approach used by the IPAC team to detect and control
outbreaks. Actions taken by the IPAC to prevent or contain outbreaks include:
o Provision of staff education to reinforce the need for implementation of precautions, based
on symptoms rather than diagnosis. This decreases the time between exposure and
transmission
o Review of each patient case thoroughly
o Focus on high risk areas such as NICU, PICU and oncology wards
o Identification of infectious agents promptly through laboratory tests
o Increased cleaning staff at units with and ongoing cluster or outbreak
o Isolation of infected patients and application of appropriate precautions promptly
o Dedication of specific equipment for infected patients
o Change of cleaning solutions and increased frequency of cleaning in the affected area.
o Establishment of housekeeping quick response teams.
In 2012/13, there were three outbreaks declared throughout PHSA facilities (Table 4).
Site
BCCH
BCCA –
Inpatient Unit
Forensics
Patients first.
When
Duration
Type
Organism
Affected
Patient #
Affected
Staff #
Apri l 2012
26 days
Gastrointestinal
Norovi rus
10
13
October 2012
16 days
Gastrointestinal
Norovi rus
3
8
December 2012
18 days
Gastrointestinal
Norovi rus
21
0
Results matter.
Best value.
Excellence through knowledge.
Page 26 of 31
7. Accreditation
PHSA and its agencies are accredited by Accreditation Canada, a national, non-profit,
independent organization that helps organizations across Canada and internationally examine
and improve the quality of service they provide to their patients and clients.
The Accreditation Canada program, Qmentum, emphasizes health system performance, risk
prevention planning, client safety, performance measurement, and governance.
During the week of June 19 -22, 2012, Accreditation Canada surveyors visited BCCH, Sunny Hill
Health Centre for Children, BCWH and BC Mental Health (Children’s). These agencies were
Accredited with Exemplary Standing.
Required by Accreditation, the Infection
Prevention & Control theme focuses on
reducing the risk of HAIs and their
impact across the care continuum. It
contains six Required Organizational
Practices (ROPs) that must be met in
order to successfully complete Accreditation.
Over the entire process of preparation
for 2012 Accreditation, the IPAC team
worked closely with all stakeholders and
demonstrated the leading practices and
delivered excellent services.
Moving forward, the IPAC will identify
opportunities for ongoing improvement
and continue to build on the successes
between now and our next survey in
2016.
INFECTION PREVENTION & CONTROL
ROP:
1. Hand hygiene education & training
Del i vers hand hygiene education and training for
staff, service providers, and volunteers.
2. Hand hygiene audit
Eval uates compliance with accepted hand hygiene
practices.
3. Infection rates
Tracks infection rates, analyses the information to
i dentify clusters, outbreaks and trends, and shares
thi s information throughout the organization.
4. Infection control guidelines
Adheres to i nternational, federal and provincial or
terri torial infection prevention and control
gui delines.
5. Influenza vaccine
Devel ops and implements a policy and procedure
for administration of the influenza vaccine.
6. Sterilization processes
Moni tors processes for reprocessing equipment
and makes improvements as appropriate.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 27 of 31
Appendix A: Infection Prevention and Control Team
Georgene Miller
Vi ce President
Quality Safety and Outcome Improvement
Alison Chant, BSN, RN, CON(C)
Infecti on Control Practi ti oner, BCCA
Kimberly Mallory, BSc, BSN, RN
Infecti on Control Practi ti oner, BCCA
Eva Thomas, MD, PhD
IPAC Medi cal Director
Medi cal Microbiologist
Laurel Nicholson, BSN, RN, CON(C)
Infecti on Control Practi ti oner, BCCA
Simon Dobson, MD
IPAC Associate Director
Infectious Diseases Specialist
Kristie Harding, BSN, RN, CON(C)
Infecti on Control Practi ti oner, BCCA
Ghada Al-Rawahi, MD
BCCA Infection Control Officer
Medi cal Microbiologist
Judy Tearoe, RN
Infecti on Control Practi ti oner, BCCA
Brenda Ryder, RN
Infecti on Control Practi ti oner, BCCA
Peter Tilley, MD
Medi cal Mi crobi ol ogi st
Ron Morley, RPN, ADPN
Infecti on Control Practi ti oner, Forensi cs
Rusung Tan, MD, PhD
Medi cal Mi crobi ol ogi st
Bonaventure Alexandre
Jun Chen Collet, B.Med, MSc, Dip. Management Hand Hygi ene (HH) Audi tor, Student Co-op
IPAC Epi demi ol ogi st
Jordan Deppiesse
Viola Tang, RN
HH Audi tor, Student Co-op
IPAC Reprocessi ng Manager
Maryam Khan
Ryanne Follett
HH Audi tor, Student Co-op
IPAC Admi ni strati ve Assi stant
Aneelma Morsara
Robyn Hunter, BSN, RN, CIC
HH Audi tor, Student Co-op
IPAC Coordi nator
Brad Procyshyn
HH Audi tor, Student Co-op
Louise Holmes, RN, CIC
Coordi nator, BCCH & BCW
Bonnie Anderson, RN
Infecti on Control Practi ti oner, BCCH & BCW
Marney Hunt, BSN, RN
Infecti on Control Practi ti oner, BCCH & BCW
Kelsi Laporte, BSN, RN, MPH
Infecti on Control Practi ti oner, BCCH & BCW
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 28 of 31
Appendix B: The patient service profile at PHSA facilities in 2012/13
Acute
Care Beds
Annual
Admissions
Annual
Outpatient visits
BC Chi ldren’s Hospital (excl. Emergency)
102
6,458
117,378
BC Chi ldren’s Hospital (Emergency only)
NA
NA
42,744
Sunny Hi ll Health Center for Children
14
221
10,045
BC Women’s Hospital (excl. Neonatal Intensive
Care Uni t ( NICU))
92
14,985
47,778
BC Women’s Hospital (NICU only)
60
1,028
NA
BC Mental Health – Children
40
529
16,783
BC Mental Health – Forensic
190
393
3,096
BC Cancer Agency (BCCA) - Vancouver Center*
26
803
120,242
BCCA – Abbotsford*
NA
NA
36,576
BCCA – Fraser Valley*
NA
NA
60,436
BCCA – Vi ctoria*
NA
NA
63,223
BCCA – Pri nce George*
NA
NA
6,277
BCCA – Kel owna*
NA
NA
47,570
BC Center of Di sease Control – TB Clinic
NA
NA
24,393
BC Center of Di sease Control – STD Clinic
NA
NA
14,843
524
24,417
611,384
Facility
PHSA Total
N/A i ndicates that this activity is not applicable.
* The outpatient visits for BCCA are the sum of the Radiation therapy visits, Systemic therapy visits, and
the Chemotherapy visits.
Source: Data provided by PHSA Performance Measurement and Reporting Group.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 29 of 31
Appendix C: Definitions
Colonization: The presence, growth, and multipl i cati on of an organi sm wi thout observabl e cl i ni cal
symptoms or i mmune reacti on. The pati ent i s asymptomati c.
Infection: Invasi on by and mul ti pl i cati on of a mi croorgani sm i n body ti ssue resul ti ng i n cl i ni cal
mani festati ons of di sease.
VRE case: Laboratory confirmation of vancomycin-resistant enterococci from speci mens i ndi cati ve of
col oni zati on or i nfecti on.
MRSA case: Laboratory confirmation of methici l l i n-resi stant Staphylococcus aureus from speci mens
i ndi cati ve of col oni zati on or i nfecti on. Thi s i ncl udes:
o Cases i denti fi ed for the fi rst ti me duri ng thei r hospi tal admi ssi on to BCCH or BCW.
o Cases identified previously at outpatient clinics but currentl y the pati ents bei ng admi tted to
BCCH or BCW wi th posi ti ve MRSA i sol ates.
o Cases identified in the emergency department that are admitted subsequently (during the same
day).
Thi s does NOT i ncl ude:
o Cases i denti fi ed i n the emergency department but are not admi tted.
o Cases i denti fi ed i n outpati ent cl i ni cs or other outpati ent cases.
o Case re-admi tted wi th MRSA.
Healthcare-Associated MRSA: A MRSA case (as defined above) identified greater than 3 cal endar days
after admission to BCCH or BCW, OR a MRSA case identified 3 calendar days or less after admi ssi on to
BCCH or BCW, but i s rel ated to a previ ous admi ssi on to BCCH or BCW wi thi n the l ast 12 months.
CDI case: Laboratory confi rmati on (posi ti ve toxi n or cul ture wi th evi dence of toxi n producti on) of
Clostridium difficile i n an unformed stool speci men (does not i ncl ude pati ents <1 year of age).
Primary CDI Infection: The first episode of CDI ever experienced OR a new episode of CDI whi ch occurs
more than 8 weeks after the previ ous toxi n-posi ti ve assay.
Continuation of the CDI infection: The subsequent positive CDI lab result(s) obtained withi n two weeks
fol l owi ng the pri mary CDI i nfecti on.
Healthcare-Associated CDI: A CDI case (including primary and relapse CDI cases) wi th symptom onset
greater than 3 calendar days or more after admissi on to BCCH or BCW, OR a CDI case wi th symptom
onset i n the community or 3 cal endar days or l ess after admi ssi on to BCCH or BCW, provi ded that
symptom onset was l ess than 8 weeks after the l ast di scharge from BCCH or BCW.
Patient days: Patient days are used as denominators in the calculati on of rates to adjust for l ength of
stay. It is calculated by the number of patients admitted at BCCH or BCW (counts are usuall y conducted
at mi dni ght) and mul ti pl i ed by the number of days of hospi tal i zati on i n a gi ven ti me peri od.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 30 of 31
Catheter-related Bloodstream Infection (CR-BSI):
Pati ent has one of the fol l owi ng:
o Non-tunnel ed CVC , coated or non-coated (e.g. pul monary artery catheter)
o Tunnel ed i nfusi on devi ce (e.g. Hi ckman, Brovi ac, tunnel ed hemodi al ysi s l i ne)
o Peri pheral l y Inserted Central Catheter (PICC l i ne)
o IVAD
AND one of the following criteria
o A recogni zed pathogen cul tured from one or more bl ood cul tures and unrel ated to an
i nfecti on at another si te.
OR
At l east one of:
o Fever >38 degrees
o Chi l l s
o Hypotensi on
AND
o Positive laboratory results unrelated to an infection at another si te that i ncl ude a common
ski n contaminant (e.g. diptheroids, Bacillus sp., coagul ase negati ve staphl ococci , vi ri di ans
group streptococci , Aerococcus sp. and Micrococcus sp.) cul tured from 2 or more bl ood
cul tures drawn on separate occasi ons wi thi n 48 hours of one another.
OR
At l east one of:
o Fever >38 degrees
o Chi l l s
o Hypotensi on
AND
o Positive laboratory results unrelated to an infection at another si te that i ncl ude a common
ski n contaminant (e.g. diptheroids, Bacillus sp., coagulase negative staphyl ococci , vi ri di ans
group streptococci , Aerococcus sp. and Micrococcus sp.) cul tured from 1 bl ood cul ture
AND
The physi ci an i nsti tutes mi crobi al therapy.
Gastrointestinal outbreak: Three or more cases of suspected gastroenteritis among patients, resi dents,
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 peri od i n the same
uni t or pati ent care area.
Respiratory outbreak: Two or more cases of influenza-like illness (fever, chills, headache, myal gi a, sore
throat, cough, nasal congestion, etc.) among patients, residents, or staff within a one-week period in the
same uni t or pati ent care area.
Patients first.
Results matter.
Best value.
Excellence through knowledge.
Page 31 of 31