January 23, 2012

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Dr. Shane Kirby General Pathologist Chair, Burnaby Hospital Infection 3935 Kincaid Street Burnaby, BC V5G 2X6 Dear Dr. Kirby:

Control Committee

Thank you for your letter of January 9, 2012. Your comments are valuable to the organization and important to address. Oostridium difficlle infection (CDr) is of major concern to Fraser Health. The high rates of CDl at Bumaby Hospital have been the focus of a number of initiatives for the past several years. We have been making signIficant strides to reduce the incidence of COl and associated morbidity and mortality,

As you indicated, CD! is a very complex problem with no simple answers. While action has to be
delivered locally it must be coordinated regionally. The issues at Burnaby are not unique to Burnaby. Program management provides a regional overview that was absent in our previous structure. Although sites no longer have Medical Directors, much of their work has been passed to an expanded physician leadership team that includes Program Medical Directors, Regional Department and Division Heads, local department leaders and a Hospital Medical Coordinator for each site. The Hospital Medical Coordinator co-chairs the Multi-disciplinary Healthcare Coordinating Committee (MHCC) with the Site Director. I am aware the Site Director for Burnaby Hospital has been heavily involved in the collaborative improvement initiatives to which I will speak below. Although still unacceptably high, CDr rates at Burnaby have improved since the implementation of program management. Your comments about administrative and organizational challenges are appreciated. Health care organizations all over the world are experiencing similar problems with respect to providing the best quality patient care within stringent fiscal budgets. I have collaborated with Dr. Andy Webb to develop a detailed response to the issues you raised, and the following paragraphs attempt to summarize some of the Fraser Health initiatives focused on CDr reduction in relation to the concerns expressed In your letter. Please feel free to' share this letter with your colleagues who co-signed your letter to me, as well as any others who you feel may benefit from the information.

Fraser Hearth Authority

the- Prestdcl'lt <lno CEO

Stilte 400, (entr-al City Tower 13450 102 <tl Avenue

Te! (604) 5874625 Fax (60'1} 587-4666

Surrey, Be V3T OHl Canada

www.fraserheaith. c~

1J Burnaby Hospital COl Action Plan: A site-specific CD! action plan was launched at Burnaby Hospital in 2009 using the COl bundle approach from Saler Healthcare Now!. The initial step of this action plan included a review of the facility infrastructure issues and housekeeping cleaning practices. Once these were reviewed, COl reduction strategies were implemented across the facility. A CD! champion worked to facilitate some of the improvement initiatives within the facility and to assist individual wards to take ownership of the project so it could become sustainable as an integral process in each patient care area. Rates dropped from highs in 2009 (2.8 cases per 10,000 patient days) to variable rates throughout 2010 - 2011 (0.9 - 2.3 cases per 10,000 patient days). During the spring and summer of 2011, the Infection Prevention and Control (IPq program developed the first definition and control protocol for CDr outbreaks in Be. This protocol enables us to quickly identify and control increases in the rate of transmissions for cor across Fraser Health. As you mentioned in your letter, this new protocol has been used at BH over the last eight months to close wards temporarily and implement strict control measures and enhanced environmental cleaning so transmission of CDI is quickly and effectively halted. 2) Program Management COl initiatives: A CD! Subcommittee has been created within the Medicine Program reporting to the Medicine Quality Performance Committee, The goal is to develop, implement and sustain a muttt-leve' (program, site and unit) model reflecting innovative and evidence-based strategies that prevent and reduce the incidence of CD! across Fraser Health with a target of 20% reduction in

Two Fraser Health facilities are particlpating in the Safer Healtl7care Now! Stop Infections collaborative led by Dr. Michael Gardam and the Canadian Patient Safety Institute. In November Dr Gardam, Director of Infection Prevention and Control and infectious disease physician from the University Health Network in Toronto, was invited by lPC to conduct an informal CDI review at Burnaby and Royal Columbian Hospitals. Dr. Gardam completed previous facility reviews for cor in Ontario, including the most recent one this summer in the Niagara region. We are in the process of planning the implementation of recommendations from Dr Gardam's report. His final report (awaited) will be a resource to continue to guide COLimprovement initiatives. His most urgent recommendation pertains to thorough and persistent sporocidal cleaning within facilities to reduce COl rates. These informal recommendations have been used to develop the standardized enhanced cleaning modules. CD! initiatives have not been restricted to the Medicine program. The Surgical program developed the Surgical Healthcare Associated Infection Prevention Excellence (SHAIPE) framework in 2010; two modules within this collaborative model aim to reduce cm and improve hand hygiene compliance. The Older Adult program has specific initiatives in place and has been successful in reducing COl within their population (see Q2 CDr rates for Older Adult Program). 3) Antimicrobial stewardship: A formal Antimicrobial Stewardship Committee (ASC) has been developed under the responsibility/leadership of the Division of Infectious Diseases. This committee is developing COl treatment guidelines, pre-printed orders and development of education programs for a broad physician/clinician base.


4) Housekeeping Services: Housekeeping initiatives and environmental cleaning are a very important part of COl prevention and reduction in any organization. IPe has been working with housekeeping services for the specific initiatives at Burnaby Hospital and at a regional level in order to standardize and maximize services across Fraser Health. IPC has developed four distinct levels of enhanced cleaning protocols to standardize cleaning processes for gastrointestinal cases (including COl) across Fraser Health. These are being reviewed and assessed for contract implications. 5) IPC Surveillance and reports: Traditional IPe surveillance reports for Healthcare Associated Infections (HAls) have been enhanced and updated. Work ls underway to automate the generation of surveillance data from Meditech. A new facility CDI report (implemented January 2011) is sent out weekly identifying the number of new cases. The intention of these reports is to raise awareness of CD! rates and the number of new cases at a local !evel to drive unit-level improvement initiatives. In addition to distribution of these reports, IPe meets with program quality committees each quarter to discuss the HAl and hand hygiene rates, including the need for improvement work by the programs. 6) Site Directors: The Site DIrectors have been a great resource for infection prevention Initiatives within facilities, Including Burnaby Hospital. Some examples include implementation of macerator and disinfectors upgrades, coordinating housekeeping services and facilities maintenance for hand hygiene and decluttering initiatives, and workIng with bed booking and congestion issues, particularly when GI or CDr outbreaks occur. They are instrumental in bringing stakeholders together during critical times such as GI outbreaks or lmplementing new IPe protocols.

7) COl Champion: The CD! champion position at Burnaby Hospital originated from a submission by the Site Director to the special one-time Quality Improvement funds made available by the Fraser Health Executive in 2010/2011. If there is a case for continuing COl champions, that case needs to be accepted by clinical programs and clinical funding prioritized appropriately.
8) Infection Prevention and Control Committees: Prior to program management, Infection Control Committees were reporting within facilities to facility leadership - Executive and Medical Directors. With the implementation of program management, the reporting structure of the infection control committees (and any other committee that is site based) moved to the facility MHCCs. Some sites did not maintain a subcommittee for infection control, preferring to include the business within the MHCC The regional Infection Prevention and Control Committee is an integral part of the quality performance structure and provides advice and analysis for implementation by cllnlcal programs. 9) Hand Hygiene: Hand hygiene has been a major initiative led by IPC over the past year. Hand hygiene rates went from 36% for 2010/11 to 56% for Q3 2011/12. Many initiatives are in place for hand hygiene such as unit-based auditing and on-line education, recognizing that appropriate hand hygiene plays an important role in reduction of HAIs across the organization. IPC Is currently


transitioning from hand hygiene as a project to a sustainment hand hygiene initiatives.

plan with clinical staff as leads on

10) Laboratory methodology for detection of C. difficile: I am informed Fraser Health currently uses two laboratory methods to detect C diffie/Ie; the C difficlle cytotoxin assay and peR testing (peR is used by SMH). The C. diffieile cytotoxin assay IS
still considered the gold standard for diagnosis and, as Significant drawback to this test is a slower turnaround PCR·based testing platform that has a similar sensitivity Laboratory leadership is looking at the funding to move such, is highly sensitive and specific. The time. The IPe program would prefer a but a faster turnaround time. the entire organization to PCR testing.

11) On-call provision of IPC:
There Is no provision for the IPC program to provide on-call coverage after hours on weekdays or on weekends; IPC covers Monday to Friday Bam - 4pm with some after hours advice given by on-call medical microbiologists. If there is a justification for continuous IPC coverage, the case and identification of the source of funds needs to be made.

12) Re-opening dosed units:
The decision to close units based on outbreak precaution definitions is considered very carefully and collabaratively with program leadership of the units along with the facility leadersn'p, physicians and laboratory findings. As you suggested, the decision to open a closed unit would only be made at the highest level of program leadership supported by the VP Medicine, Dr. Webb.

13) On~Going Challenges:
The scope of responsibilities for lPC has broadened to encompass community. It is true the resource availabllity to cover this has been limited. Part of the solution to this is the cultural shift where the lPC program staff function as consultants to develop material, polkles, clinical practice guidelines while clinical programs embed the infection prevention and control standards and best practices as part of the professional duties of front-line staff, This cultural shift is ongoing. Additionally, it was recognized that with the increase in workload and limited additional resources, lPCs would have to consider prioritization of work such as the triage model in Ontario. IPCs have developed a triage list based on a risk assessment. Hand hygiene and COl are at the highest priority. Some accountability and responsibility for infection prevention initiatives within facilities changed from facility-based to program-based with the move to program management. While this has provided opportunities to standardize infection control initiatives across the region, I agree that implementation is sometimes difficult where it is necessarily facility-based. The balance between program-based and facility-based initiatives will evolve as the program management model matures, The comments regarding medical support are well known; this has been a long-standing issue. The role description for the Program Medical Director position for IPC has been revised and advertised. We need this position to work in conjunction with the regional medical microbiologists and the medica! leadership described in the opening paragraph. This collaborative approach aligns with the program management model of embedding infection prevention and control initiatives within clinical role responsibilities. There was no internal


interest in the position so we are moving to an external search. Dr. Roberts has agreed to stay on for the present time while the search continues but we are aware he wishes to retire ..The role of the Medical Microbiologlsts and Infectious Disease physicians within the IPC program is

under review. Thank you for taking the time to voice your concerns. You are welcome to discuss your concerns regarding specifics of Burnaby cm initiatives, rates, morbidity and mortality and tlmel.nes for implementation of initiatives in further detail with the IPC program, who will contact you to set up a specific time to meet in person.

Dr. Nigel Murray President and Chief Executive Officer NJMjtls
Cc: Dr. Andrew Webb, VP Medicine

Marc Pelletier, VP Clinical Operations Cathie Heritage,Executive Director Sheila Finamore, Site Director, Burnaby Hospital Petra Welsh, Administrative Director, Infection Control Dr. Fred Roberts, Program Medical Director, Infection Control