“lessons learned” from infection control resource teams (icrt)s/volkening_lessons... · icrt...

“Lessons Learned” from Infection Control Resource Teams (ICRT)

Grace Volkening, IPAC Specialist

Public Health Ontario (PHO)

IPAC-SWO Chapter Education

November 14, 2014

PublicHealthOntario.ca

Outline

• Overview of the various models for IPAC response and support at PHO • Infection Control Resource Teams (ICRT)

• IPAC Review Pilot Program (IRP)

• IPAC Lapse

• ICRT process/tools

• Key findings / “lessons learned”

• Turning “lessons learned” into prevention strategies

• Questions?

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http://www.publichealthontario.ca/


Infection Control Resource Teams (ICRT)

• Implemented in 2008 by MOHLTC to respond to Clostridium difficile infection (CDI) and provide support to hospitals and public health units in managing CDI outbreaks

• Visits have expanded to include support for non-CDI outbreaks e.g. AROs, enteric and respiratory outbreaks, and beyond hospital setting, i.e. several visits to LTC homes

• Since 2013, team has been drawn entirely from PHO staff

• Process has evolved to provide a more consistent/structured assessment of IPAC practices that may be contributing to outbreak



IPAC Program Review (IRP)

• RICNs provide ad hoc support to LTC homes on request as required

• Pilot program that originated in the South Western Ontario Infection Control Network (SWOICN) in partnership with the London Middlesex Health Unit to explore ways to better support LTC homes

• Visits involved a “walk-about” with the facility’s ICP and identification of areas for improvement using an audit tool based on IPAC best practices

• Report developed with pictures shared with the ICP for follow up

4 Photo Credit: Microsoft Clipart



IPAC Program Review (IRP)

• Program piloted in 6 RICNs

• Results being evaluated by a small working group and report being developed

• Future direction to be discussed/determined

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IPAC Lapse

• Response to an incident/investigation in outpatient healthcare setting related to: • a breach in IPAC practice with identified transmission; or • a case/cluster of infection with/without identified breach

• Link can be a procedure, a facility or an individual e.g. HCP

• In general, situation is being investigated by a local public health unit (PHU) that identifies a “lapse” in IPAC practices

• PHU contacts PHO

• PHU looking to PHO for guidance/support: • Literature review on the issue • Provision of IPAC resources • On-site review of IPAC practices e.g. ICRT visit

• Coordination with MOHLTC

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Infection Control Resource Teams (ICRTs)


Goal of ICRT

• The overall goal of the ICRT is: • To provide expert scientific advice on infection prevention and control

issues that may be contributing to the issues in the organization.

• To provide a ‘second set of eyes’ to assist the organization in identifying potential issues and providing recommendations to assist in rectifying these

• The visit is conducted in a supportive manner and the team focus is on identifying root causes and providing recommendations to assist in the overall management of the outbreak

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ICRT Visits by Outbreak Type – 2008 to 2014

24 4

4

3

2 1

N = 38

CDI only

CDI + ARO

VRE

MRSA/VRE

Resp/Enteric

Hep C



ICRT Visits by Setting – 2008 to 2014

22

6

6

4

Lg comm.hospital

Academic

Sm comm/rural hosp

LTC home

N = 38



ICRT Process

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Request via IPAC mailbox

On-site Visit - Interviews

Pre-visit Questionnaire

On-site Visit - Tours Share priority issues

Final Report Issued Follow-up Visit Assess trends

Photo Credit: Microsoft Clipart

Assign Team/Arrange Visit



Pre-visit Questionnaire – Self Assessment

• Provides overview of the facility and the situation

• Gathers demographic and other info prior to visit • Number of beds

• Services provided

• Staffing

• Epidemiological info related to current outbreak

• Specific practice questions e.g. screening for AROs



Pre-visit Questionnaire

SECTION A – GENERAL INFORMATION

Surveillance and Epidemiology

1. Currently, what outbreak organism(s) are you dealing with in your institution?

Clostridium difficile

MRSA

VRE

Other

2. What is the case definition used to count patients in your facility’s current outbreak?

3. What is the outbreak definition that your facility uses with respect to the current outbreak organism?



ICRT Visit – Interviews

• Introductory overview • Validates our understanding of the situation and clarifies issues

• Interviews with key individuals and departments • Key departments include Senior Leadership, IPAC, Nursing,

Environmental Services, +/- Patient Flow, Pharmacy, Occupational Health, Staffing etc. depending on issue

• Obtain more detailed information regarding policies and practices

• Selection of questions posed to help identify gaps in practice



Sample Interview Questions

ICP and Front-line Staff:

• Are policies and procedures related to outbreak management available and easily accessible?

• Is there timely and consistent identification of patients/residents with symptoms of infection? How is this done?

• For patients/residents with symptoms of infection, when are Additional Precautions initiated?

• Who discontinues Additional Precautions and when is that done?



ICRT Visit – The Tour

Opportunity to :

• See practices in action and validate what we heard

• Speak with staff, ask questions, clarify our understanding of issues

• Identify gaps in facility design e.g. shared washrooms, worn environmental surfaces; patient flow (tour generally includes Emergency department in hospital settings); equipment and supplies management e.g. clutter, storage



Sample Checklist Checklist – Tour of Affected Unit(s)

Item Yes No Comments Is the overall appearance of the unit clean and

tidy?

Does the policy and procedure for shared

patient care equipment clearly define the

process and personnel responsible for

cleaning?

Are unit staff able to identify who is

responsible for cleaning and the process?

Is signage for patients on Additional

Precautions clearly posted on entry to the

patient’s room/environment?

Is point of care hand hygiene product

available?

Is point of care PPE available?

If patients are cohorted are staff able to identify

the rationale for cohorting?

Do isolated patients have dedicated toileting

facilities? Describe process used.

Are supplies such as lotions, creams shared

between patients?

Does staff consume food or beverages on the

patient care unit?

Have all staff received education on

management of CDAD?

Is extra equipment stored in patient

room/environment?

Are supplies in patient environment sufficient

only for one shift?


Key Findings from ICRTs “Lessons Learned”


Key Findings

• Policies and procedures not always consistent with observed practices (or vice versa)

• Practices implemented to address “the outbreak” are generally consistent with best practice. Non-compliance appears to be more in the area of Routine Practices i.e. outbreak prevention



Lessons Learned

• Prevention is always better than control

• A number of issues contribute to outbreaks – generally not just one

• Facilities have the resources to assist in outbreak prevention • PIDAC best practice documents

• Human resources

• Local public health units

• IPAC-Canada Chapter

• Public Health Ontario (PHO)

• Peers/colleagues

• Our own staff

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IPAC Program Issues:

• IPAC staffing – below best practice or based on bed #s alone

• Medical leadership – no physician lead/champion for IPAC

• Reporting relationship – IPAC not reporting to senior leader

• IPAC Committee – no committee or dysfunctional

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IPAC Practices

Issues:

• Initiation/Discontinuation of Precautions • Lack of timely implementation of additional precautions

• Precautions discontinued without consultation with IPAC

• Hand hygiene • No hand hygiene program in place

• No point-of-care ABHR

• No audits conducted

• Auditing done but results not shared

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IPAC Practices

Issues:

• Personal Protective Equipment (PPE) • Not accessible

• Staff unaware of appropriate PPE for various types of situations or precautions

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Outbreak Management

• Overall: • No Outbreak Management Team (OMT)

• Decisions made outside OMT meetings and not shared

• Corporate support wanes when outbreak prolonged

• No debrief or follow through with “lessons learned”

• Surveillance: • Non-adherence to PIDAC case definition for CDI

• Screening for AROs not conducted in a timely manner

• Recognition of patients/residents with symptoms of infection e.g. gastro or acute respiratory infection and timely action not consistent among front-line staff

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Outbreak Management

• Patient flow: • Frequent bed moves increase risk of exposure and demand for

discharge cleaning

• Communication & Partnerships • Poor communication and working relationship between IPAC team and

units, and/or other departments e.g. ES, Occupational Health

• Collaboration between Public Health Unit and facility is ineffective

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Environment & Equipment

• Issues • Confusion related to product selection

• Impact of increased use of sporicidal agents on equipment

• Shared toilet brushes

• Insufficient staff for outbreak response

• No monitoring of cleaning practices

• Designation of responsibility for cleaning mobile equipment not clearly defined – everyone’s responsible = no one’s responsible

• No system for identifying clean and dirty items

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Human Waste Management

• Issues • No facility-wide system for containment of feces (e.g. hygienic bags,

macerators, washers-disinfectors)

• Shared commode chairs (insufficient numbers)

• Spray wands still in use

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Education

• No regular/ongoing education for staff or physicians

• IPAC not included in development of educational materials

• Resources provided by PHU and PHO not accessible to staff

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Antimicrobial Stewardship

• No stewardship program in place or program in progress but insufficient resources to support it

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TURNING “LESSONS LEARNED” INTO PREVENTION STRATEGIES

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IPAC Program

• Staffing • Consistent with programs as well as beds

• Ability to ramp up in response to outbreaks with no impact on day-to-day (prevention)

• Knowledgeable ICPs, ideally CIC

• Medical leadership • Access to a physician with IPAC knowledge/expertise

• In-house physician champion to support (and model) IPAC activities

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IPAC Program • Reporting relationship

• IPAC Committee (IPACC)

• Well functioning, multi-disciplinary committee (including representation from senior leadership)

• Meets regularly to discuss issues/ make recommendations

• Support the implementation and execution of the program by IPAC staff

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The ICP(s) should have direct access to the Senior Management individual who is accountable for the organization’s program and who can facilitate

the actions that are required.

All health care facilities must have a formal committee structure to oversee the activities of the IPAC program. Photo Credit: Microsoft Clipart



IPAC Practices

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• Initiation of Precautions

Each health care setting should have a policy authorizing

any regulated health care professional to initiate the appropriate Additional Precautions at the onset of

symptoms and maintain precautions until laboratory results are available to confirm or rule out the diagnosis.



IPAC Practices

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The health care setting should have a policy that permits discontinuation of Additional Precautions in consultation with

the ICP or designate.

• Discontinuation of precautions



IPAC Practices

Hand Hygiene

All health care settings must implement a hand hygiene program which incorporates the following elements:

• a written policy and procedure regarding hand hygiene

• easy access to hand hygiene agents at point-of-care (70-90% ABHR is preferred and must be provided by the health care setting)

• education that includes indications for hand hygiene, techniques, indications for hand hygiene agents and hand care

• a hand care program

• a program to monitor hand hygiene compliance with audits of hand hygiene practices and feedback to individual employees, managers, chiefs of service and the Medical Advisory Committee via the Infection Prevention and Control Committee

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Best Practices for Infection Prevention and Control Programs in Ontario | May, 2012



IPAC Practices

Hand Hygiene

• Hand hygiene program which includes: • Point-of-care ABHR

• Education and training

• Auditing/ feedback

• PPE • Right PPE – Right place – Right time

• Specific to type of precautions

• Available at the point-of-care

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Outbreak Management

• Overall: • Multidisciplinary outbreak management team (OMT) established at

initiation of outbreak

• OMT has authority to institute changes in practices or take other actions that are required to control the outbreak

• Clear communication policies and procedures in place

• Adequate numbers of staff with appropriate training to increase staffing capacity during outbreaks (e.g. geographically cohort nursing staff)

• IPAC team has authority to implement outbreak measures up to and including closure of affected units

• Corporate support throughout the outbreak (organizational priority)

• Debrief held at end of outbreak to review “lessons learned”

•

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Outbreak Management

Surveillance

• CDI • Ensure timely turnaround of lab results

• Correlation between lab results and patient signs and symptoms (PIDAC case definition)

• AROs • High risk patients/residents screened within 24 hrs of admission

• Patients/residents with exposure e.g. contacts of cases, are placed on Contact Precautions and rescreened (2 sets of specimens taken on different days, with one taken a minimum 7 days after last exposure)

• Coordination with lab for timely reporting of suspect AROs

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Outbreak Management

Surveillance

• Other – Respiratory and Enteric • Staff engagement in monitoring/identifying patients or residents with

new or worse symptoms of infection and taking action i.e. initiating Additional Precautions

• Timely notification of ICP and health unit re: potential outbreak

• Monitoring of staff illness

• Key prevention strategy for respiratory outbreaks:

• Provide annual Influenza vaccination to staff, patients/residents

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Outbreak Management

• Patient flow: • Bed moves should be done for medical purposes only (not patient

convenience)

• Communication & Partnerships • Good communication between IPAC team and units

• IPAC team has good working relationship with Environmental Services

• IPAC team has good partnership with Occupational Health and Safety Department

• Collaboration between Public Health Unit and facility is effective

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• Cleaning performed on a routine and consistent basis • Written policies and procedures with clear accountabilities and cleaning

protocols

• Adequate resources dedicated to Environmental Services to allow thorough and timely cleaning and disinfection; appropriate levels of supervisory staff

• Clarity around which product to use for routine/additional cleaning

• Education program in place for new and experienced ES staff

• Process is in place for cleaning of shared patient /resident equipment

• System for identification and storage of clean and dirty equipment

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• Toilet brushes/ swabs should not be carried from room-to-room (remain in the room or use disposable)

Environmental Cleaning for CDI:

• Twice daily cleaning of patient/resident room using hospital grade disinfectant or sporicide

• Daily cleaning of patient/resident bathroom/commode with a sporicide

• Use of sporicide for cleaning of patient/resident room on transfer/discharge or discontinuation of contact precautions.

• Double clean room on patient/resident discharge/transfer

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Human Waste Management

• Implement facility-wide system for containment of feces

• Handle commodes and bedpans very carefully to reduce spread of contamination with C. difficile spores from the commode/ bedpan to the environment: • Dedicate commode chair to the patient/resident

• Clean and disinfect commode with a sporicide whenever the room/ bathroom is cleaned; also, when precautions are discontinued before using with another patient/resident

• Disposable bedpans strongly recommended

• Bedpan cleaning wands or toilet taps should not be used

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Education

• IPAC education and training on Routine Practices/Additional Precautions (RP/AP) • All staff on hire - orientation

• Ongoing continuing education

• Physician education (consider as part of credentialing?)

• IPAC actively participates in the planning and implementation of education

• Includes (at a minimum) – hand hygiene, appropriate selection and use of PPE (for both RP and AP)

• IPAC resources and tools to support staff and assist with decision-making are accessible at the front-line

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Antimicrobial Stewardship

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• Antimicrobial Stewardship Program (ASP) in place

• Dedicated resources to support the program



Prevention Strategies - Summary • Staff engagement in surveillance – early identification and

management of patients/residents with infection or colonization

• Robust hand hygiene program – POC ABHR, education, audits

• Accessible PPE and staff education (what to wear and how to wear it – donning/doffing)

• Good routine cleaning practices and monitoring process; system for equipment cleaning (what, how and who) and identification of clean/dirty

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Prevention Strategies

• Facility-wide system for human waste management

• Annual Influenza vaccination for patients/residents and staff

• Well functioning IPACC and core OMT

• IPAC as an organizational priority – support from senior leadership

• ICP/IPAC Team that is knowledgeable, approachable and respected; good working relationship and communication with departments/units

• Regular monitoring of IPAC practices

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Auditing IPAC Practice

“Health care settings must monitor targeted IPAC processes with regular audits of practices.” Best Practices for Infection Prevention and Control Programs in Ontario | May, 2012

Process in place for monitoring staff compliance to IPAC policies and procedures through regular audits of IPAC practices:

• Hand hygiene compliance

• Environmental cleaning

• Cleaning of shared patient/resident equipment

• Routine Practices/ Additional Precautions through monitoring proper use of PPE



How can we help?

• Assistance available through IPAC-Canada, PHUs and RICNs • Checklists/ audit tools

• Surveillance resources

• Sample signage for AP

• Support for staff education/training

• Other resources available from PHO • Core Competency modules

• Environmental Cleaning Toolkit

• Disease specific info on website e.g. CDI

Visit http://www.publichealthontario.ca/en/Pages/default.aspx

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http://www.publichealthontario.ca/en/Pages/default.aspx

http://www.publichealthontario.ca/en/Pages/default.aspx

PublicHealthOntario.ca 50 PublicHealthOntario.ca

Photo Credit: Microsoft Clipart




Thank you!

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