Report - March 14, 2008

[Current Issue -Table of content]

Healthcare-associated infection practices and resources among provinces and territories in Canada: results of a survey

JS Spika, MD (1), S Lachapelle, MA (1), D Patrick, MD (2)

1. Infectious Diseases and Emergency Preparedness Branch, Public Health Agency of Canada, Ottawa, Ontario
2. British Columbia Centre for Disease Control, Vancouver, British Columbia

An estimated 8 000 persons die in Canadian hospitals each year as a result of infections acquired during their hospitalization¹ .  Ongoing problems in hospitals with methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile-associated diarrhoea (CDAD) exist^2,3  and community-acquired MRSA outbreaks are also being reported in Canadian cities and in northern regions^4,5.

On behalf of the Communicable Disease Control Expert Group, Pan-Canadian Public Health Network, a survey was undertaken late 2007 and early 2008 of Canadian public health officials in provincial and territorial ministries of health to ascertain current activities and capacities related to healthcare-associated infections (HAI).  HAI were defined as those acquired as a direct result of healthcare (within or outside institutions) and those due to antimicrobial-resistant bacteria in the community, where resistance has emerged as a result of healthcare use of antimicrobials.

Responses were received from all 13 provinces and territories (P/Ts). While 12 reported they currently had HAI functions/capacity within public health, eight had established these functions within the last 10 years; three others were unable to provide a date.  Five jurisdictions had legislation that defined these responsibilities.  Among the 12, the number that undertook the following activities is included in parenthesis: surveillance (9); produce guidelines (9); coordinate ad hoc group of experts (6); have an infection control office (5); have regional HAI public health functions (5); coordinate public health activities for HAI (5); coordinate healthcare-related activities for HAI (5); serve as secretariat for a formal advisory body (4); and maintain linkages with healthcare quality assurance programs (4).  The part of the ministry of health identified as being primarily responsible for HAI is shown in Figure 1.

The main sources of information on HAI used by jurisdictions included the following (number in parenthesis): guidelines produced by Public Health Agency of Canada (13); guidelines produced by the Centers for Diseases Control and Prevention (13); experts from within the jurisdiction (10); experts from outside the jurisdiction (9); formal advisory group (7); and Safer healthcare now! protocols (4).

Nine jurisdictions were aware of hospitals participating in the Canadian nosocomial infection surveillance program (CNISP) and nine were also aware of hospitals participating in the Canadian Patient Safety Institute’s Safer healthcare now! programs; however, only one jurisdiction for each of the two program areas stated they received reports from participating hospitals.  Ten P/Ts were doing or were in the process of implementing surveillance for MRSA and for CDAD.

The sources of HAI training used in the jurisdictions included the following (number in parenthesis): in service in hospitals/institutions (12); web-based learning tools (11); institution-based grants or supplements to persons seeking certification (7); university-based programs in the jurisdiction (4); educational grants from government to persons seeking certification (2); and certified training programs in jurisdiction (2).  When asked to estimate the percentage of hospitals and long-term care facilities with the recommended number of certified infection control practitioners⁶ , the results were: ≥ 80% (1); 50% to 79% (2); 25% to 49% (3); < 25% (6); and don’t know (1).

Respondents identified the following as the most important issues needing to be addressed to strengthen provincial/territorial and national capacity to respond to HAI (number identifying in parenthesis) (Table 1): activities that could be grouped within the heading of national framework or approach (9); issues that could be grouped as training (9); and issues related to resources at the provincial/territorial level (6).

Discussion

The survey was intended to provide a rapid assessment of current activities and needs for HAI as observed by provincial and territorial public health officials.  Activities for HAI at this level have only recently been initiated in many jurisdictions; and in many, the group primarily responsible for HAI within ministries of health does not appear to be well defined.

Important needs were identified, including the need to create a national framework for all existing partners, ensuring the important roles each play are clearly recognized and the information from surveillance activities and on successful interventions is readily available to those that need to know. 

Training was also a very important issue.  While most jurisdictions relied on health facility-based training, most may have < 50% of their facilities with the recommended number of infection control practitioners (ICP).  A few jurisdictions have certified training programs for ICP, but the most available ICP training was through web-based learning tools.  An expansion of training opportunities needs to be addressed.

Table 1. Healthcare-associated infection issues identified by provincial and territorial public health respondents (n = 13)

National framework/approach (9 jurisdictions identified): Clearly define roles of all partners Surveillance – case definitions; standards/validated measures; flow of information through P/Ts; information technology infrastructure; broaden participation to make more representative; include community surveillance for antibiotic-resistant organisms. Guidelines – maintain/update existing ones and ensure continuation with national coordination; share best practices; use measurable processes and outcomes; ensure linkage between P/Ts processes and documents and those of other partners, e.g., the Canadian Standards Association, the Canadian Patient Safety Institute and the Public Health Agency of Canada; develop guidelines for reprocessing of single use devices. Research – effectiveness of disinfection and of techniques related to hygiene, including factors having an impact on engaging healthcare workers and  organization of their work. Regulatory activities – assess cleaning instructions as part of approval process; standards for and monitoring of reprocessing; HAI issues considered when approving antibiotics and disinfectants. Training (9 jurisdictions identified): Availability of well-trained human resources Core competencies Resources for programs in jurisdiction (6 jurisdictions identified): Consider an essential service Prioritize it within the patient care/safety area Regional support for meeting Canadian Council on Health Services Accreditation standards Support from the Public Health Agency of Canada

 

Figure 1.  Primary responsibility for healthcare-associated infections within provincial and territorial ministries of health (n = 13)

References

1. Zoutman DE, Ford BD, Bryce E et al. The state of infection surveillance and control in Canadian acute care hospitals. Am J Infect Control 2003;31:266-72.
2. Simor AE, Ofner-Agostini M, Gravel D et al. Surveillance for methicillin-resistant Staphylococcus aureus in Canadian hospitals – a report update from the Canadian Nosocomial Infection Surveillance Program. CCDR 2005;31:33-40.
3. Loo VG, Poirier L, Miller MA et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442-49.
4. Gilbert M, MacDonald J, Louie M et al. Prevalence of USA300 colonization or infection and associated variables during an outbreak of community-associated methicillin-resistant Staphylococcus aureus in a marginalized urban population. Can J Infect Dis Med Microbiol 2007;18:357-62.
5. Wylie JL, Nowicki DL. Molecular epidemiology of community- and healthcare-associated methicillin-resistant Staphylococcus aureus in Manitoba, Canada. J Clin Microbiol 2005;43:2830-36.
6. Health Canada. Development of a resource model for infection prevention and control programs in acute, long term and home care settings:Conference proceedings of the Infection Prevention and Control Alliance. Can J Infect Control 2001;6:35-39.