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Advancing Infection Prevention and Control Best Practices in the Emergency
Department
Executive Summary
February 1, 2012
CONTEXT
The Ontario government continues to move forward with a comprehensive strategy to improve
the quality and accountability of the health system.
In alignment with the province’s quality direction, and to advance quality at the local system
level, in August 2011, the Central Local Health Integration Network (LHIN) released its Quality
Action Plan, Patients First: An Action Plan to Improve Quality in the Transitions of Care. As part
of this Quality Action Plan, Central LHIN is working to help strengthen health provider capacity
to support continuous quality improvement within the LHIN.
Specifically, Central LHIN has been working with LHIN health service providers to explore
patient flow improvement initiatives and how they can be optimized to improve outcomes,
reduce patient wait times and improve length of stay.
On September 22, 2011, Central LHIN brought together clinical and administrative
representatives from all acute care hospitals in the LHIN and the Central CCAC to attend
Improving Quality in Emergency Departments by Enhancing Flow: An Emergency Department
Quality Collaborative, the first in a series of quality collaboratives being implemented by the
Central LHIN. The collaborative sought to explore the linkages between longer lengths of stay
and patient quality/outcomes with the goal to identify organizational and system wide strategies
for improvement.
As a key next step from this session, and to inform ongoing collaboration between the LHIN and
hospitals regarding the current challenges surrounding Emergency Department (ED) length of
stay, Central LHIN hospitals undertook a chart review of patients waiting longer than 90 hours
before being admitted to investigate the most prevalent causes of higher ED length of stay. The
chart review reported infection prevention and control (IPAC) as a top factor affecting patient
length of stay.
PURPOSE AND OBJECTIVES
Ontario has taken a number of important steps to improve IPAC systems. New legislation, the
Health System Improvements Act, 2007, established the first Ontario Agency for Health
Protection and Promotion, now Public Health Ontario (PHO). Mandatory reporting of infectious
disease outbreaks were instituted, as well as required best practices for the control of those
infected or colonized with infectious diseases.
1
These enhancements have largely been in response to the increasing prevalence of many
infectious diseases. For example, in the last ten years the number of patients colonized or
infected with methicillin-resistant Staphylococcus aureus (MRSA) in Ontario has increased from
7,684 to 21,002, roughly a three-fold increase. The number of patients colonized or infected with
vancomycin-resistant Enterococcus (VRE) in Ontario increased from 237 to 5,567 in the same
ten year period. Also, new antibiotic-resistant infectious diseases, such as carbapenemresistant Enterobacteriaceae (CRE) have become more prevalent. 1
On December 13, 2011, Central LHIN organized the Advancing Infection Prevention and
Control Best Practices in the Emergency Department Quality Collaborative to explore the
relationship between IPAC and ED length of stay.
The Collaborative’s learning objectives included the following:
•
•
•
•
Review rationale and basic concepts of IPAC interventions (including routine practices
and additional precautions) with an emphasis on patient and staff safety.
Review the complexity of current standards, accountabilities, legislated responsibilities,
and patient safety public reporting related to IPAC.
Explore available data and share perspectives on additional precautions (e.g. isolation)
and their impact on patient flow.
Share experiences and identify strategies to optimize flow of ED patients requiring
additional IPAC precautions.
This Collaborative sought to explore the linkages between IPAC and higher ED lengths of stay
with the goal to identify organizational and system-wide strategies for improvement. The
discussion also provided an opportunity to hear examples of initiatives that are sustaining
positive results within the local system.
DISCUSSION SUMMARY
The session began with opening remarks from Victoria van Hemert, Senior Director of Planning,
Integration and Community Engagement at the Central LHIN. Ms. van Hemert outlined the
context for focusing on IPAC. Central LHIN hospitals have committed to improving IPAC as part
of their Quality Improvement Plans, and as a result, the session provided Central LHIN health
service providers with an opportunity to share meaningful knowledge regarding initiatives,
successes and challenges from IPAC at Central LHIN hospitals.
Following opening remarks, Dr. Rakesh Kumar, Director of Medicine, Critical Care, and
Emergency Medicine, at York Central Hospital, and the Central LHIN ED Lead, provided short
remarks.
Dr. Kumar highlighted that in the last ten years a number of events resulting from emerging
infectious diseases have heightened the focus on IPAC in Ontario. Most notably, in 2003, an
outbreak of severe acute respiratory syndrome (SARS) exposed the challenges in the Ontario
health care system to effectively deal with the spread of infectious diseases. In response, the
government put in place new enhanced infection control procedures at all levels of the health
care system.
2
The importance of reform and the need for system focus on infection prevention and control in
all health care settings was highlighted further by the 2005 outbreak of Legionnaires’ disease in
a long-term care home in Toronto, and by the recent nosocomial Clostridium difficile outbreaks
in Ontario.
Grace Volkening, Network Coordinator for the Regional Infection Control Network (RICN) –
Central Region of PHO, then provided an overview of the role of PHO and more specifically the
RICNs in advancing IPAC across Ontario.
She outlined that IPAC programs are designed to:
•
•
•
Protect the health of patients and care providers and to improve outcomes for patients.
Prevent and control the spread of infections and infectious microorganisms through the
use of best practices.
Lessen the impact of infections on the health care system.
Included in PHO’s role is the provision of expert scientific and technical support relating to IPAC.
PHO has a number of programs relevant to IPAC including infection control operations (public
reporting, involvement in outbreaks), infection control resources, the RICNs, and the Provincial
Infectious Diseases Advisory Committee (PIDAC).
The RICNs are mandated to assist with the standardization of IPAC and are available to work
with health care providers in developing their IPAC programs.
PIDAC is a multidisciplinary committee of health care professionals with expertise and
experience in IPAC. It advises PHO on the prevention and control of health care associated
infections and produces evidence-based best practice knowledge products to assist health care
organizations.
PIDAC best practices, considered the “gold standard” in Ontario, are based on current scientific
evidence and outline mandatory legislated requirements, national standards and advisory
recommendations. PIDAC has published best practice manuals and fact sheets for many IPACrelated topics including environmental cleaning, hand hygiene, routine practices and additional
precautions, antibiotic resistant organisms and acute respiratory infections. All PIDAC
knowledge
products
can
be
found
at:
http://www.oahpp.ca/resources/pidacknowledge/index.html.
Routine Practices and Additional Precautions
Ms. Volkening discussed how routine practices create a system that prevents the acquisition of
disease from patient to patient, patient to staff, staff to patient, and staff to staff.
Routine precautions include risk assessment, hand hygiene, environmental controls (including
appropriate placement and bed spacing, cleaning of equipment, cleaning of the healthcare
environment, engineering controls, and point-of-care sharps containers), administrative controls
(policies and procedures, staff education, healthy workplace policies, immunization programs,
respiratory etiquette, monitoring of compliance, and sufficient staffing levels), and the use of
sufficient, easily accessible and appropriate barrier equipment.
3
The use of additional precautions is always suggested in addition to routine practices for
patients known or suspected to be infected or colonized with certain microorganisms to prevent
transmission.
Additional precautions should be instituted once symptoms that suggest an infection are
noticed; however in some cases initiating additional precautions prior to a firm diagnosis may be
appropriate. Screening for antibiotic resistant organisms (AROs) at the earliest possible time
helps avoid preventable exposures and room transfers.
Guidelines are often infection-specific and based on whether the infection is transmitted through
contact, air, or droplet. Additional precautions may include specialized accommodation and
signage, barrier equipment, dedicated equipment, additional cleaning measures, transport
considerations, and communication.
Discontinuing IPAC precautions requires consultation with an IPAC professional. Individuals
may remain colonized with AROs for weeks or months and it is not currently known how long
bowel colonization persists for extended-spectrum b-lactamase-producing bacteria or CRE.
Antibiotic Resistant Organisms and Acute Respiratory Infections (ARIs)
Ms. Volkening also highlighted the negative impact AROs and ARIs have on patient care and
the health care system. AROs negatively impact an individual’s length of stay and quality of life.
AROs risk the possibility of serious complications including mortality and are associated with
increased cost to the health system and challenges to the provision of quality patient care.
ARIs are a major cause of illness, absenteeism, lost productivity and death. ARIs also affect the
flow of patients in the ED due to surges of influenza in the winter months. In Canada, influenza
and community-acquired pneumonia account for 60,000 hospitalizations and 8,000 deaths
annually, and are the leading cause of death from infectious disease. 2 Influenza outbreaks can
close a unit for 10 to 14 days and outbreaks in long-term care facilities impact the transfer of
patients. 3
Ms. Volkening emphasized CRE as an emerging issue of increasing concern for Ontario health
service providers. Treatment of CRE infections are difficult and involve the use of antibiotics
with poor adverse event profiles. The case fatality rate for serious CRE infections may be as
high as 50%. 4 PIDAC has revised their recommendations for AROs to include recommendations
for CRE.
Strategies to Optimize Flow of ED Patients on Additional Precautions
Following Ms. Volkening, Dr. Kevin Katz, Medical Director of Infection Prevention and Control at
North York General Hospital, discussed relevant research and provided a data-driven summary
of the current infection prevention and control environment.
Published research from the Institute of Medicine reported nosocomial infections as the second
most prevalent cause of preventable mortality. Infections result in significant mortality and
economic costs to the health care system. For example, patients with MRSA have a 2-3 times
greater relative risk of death compared to those with methicillin-sensitive Staphylococcus aureus
(MSSA). Compared to MSSA, per case MRSA treatment costs are $14,000-$25,000 more and
4
result in an additional length of stay of approximately 8 days. MRSA is estimated to now be
costing Canadian hospitals $50-$60 million per year. 5
Regarding ARIs, following SARS, Ontario instituted standards for the control and surveillance
for ARI in acute care institutions. Testing to confirm cases can at times be challenging due to a
lack of influenza testing on site, or the utilization of a test that produces a large amount of false
positives.
Dr. Katz shared how North York General Hospital (NYGH) implemented molecular testing for
influenza two years ago with positive results. Chart reviews from last season of 40 individuals
who tested positive for influenza and 40 individuals who tested negative showed a reduced
length of stay in isolation of 3.3 days for positive cases and 2.4 days in flu negative cases. 6
A research paper by Dr. Steven J. Drews, Dr. Janet Raboud, and Dr. Kevin Katz, No Room at
the Inn: Fever and Respiratory Illness Precautions and the Placement of Patients Within an
Ontario Acute Care Institution, investigated the difference in the median time to an inpatient
acute care bed for patients who presented to NYGH with or without ARI.
The study found that the median time to bed placement was significantly higher for patients with
ARI (compared to those without ARI) in medicine, where only 25% of the beds are single-bed
rooms, but not significantly different in pediatrics, where all rooms are single-bed rooms. These
findings highlight the importance of single-bed rooms for ensuring timely admission of patients
requiring isolation precautions. 7
Changes to IPAC practices in Ontario instituted following SARS have resulted in challenges for
hospitals in placing infected or colonized individuals. Many hospitals currently function near
100% occupancy with very little surge capacity.
According to Dr. Katz, creative hospital resource management can be used to optimize the
availability and use of single bed rooms. The cohorting of patients who are infected or colonized
with the same micro-organism through placement in the same room, or at times, in an entire unit
(in the case of larger outbreaks), is another creative solution possible.
Evidence has shown that the transmission of AROs is directly related to infection prevention and
control practices in healthcare settings. Since most nosocomial MRSA infections result from
patient-to-patient transmission, screening of exposed roommates is vital to prevent further
transmission. An infection prevention and control program for MRSA and VRE that emphasizes
early identification of colonized individuals through active surveillance reduces the prevalence
and incidence of both colonization and infection, improves patient outcomes, and reduces
healthcare costs. 8
Research conducted at NYGH between June 2005 and February 2010 found that roommates
exposed to MRSA patients for greater than 48 hours were more likely to acquire MRSA (11%)
compared to roommates with an exposure equal to or less than 48 hours (6%). 9
Dr. Katz argued that increased communication between hospitals and long-term care homes
would aid in improving patient flow. Ensuring that health care providers are receiving accurate
data regarding the infection or colonization status of a patient, and clarifying when from a health
system perspective it is appropriate for a patient to be transferring during infection outbreaks will
help in reducing system pressures.
5
INTERACTIVE PANEL DISCUSSION
The discussion then moved into a panel component with six representatives from Central LHIN
hospitals offering their reflections on successful IPAC initiatives as well as existing challenges.
Panel participants included:
•
•
•
•
•
Ms. Bridgette Boaretto, Manager, Infection Prevention and Control, Southlake Regional
Health Centre
Ms. Nataly Farshait, Director, Infection Prevention and Control, Humber River Regional
Hospital
Ms. Susanne Parker, Infection Prevention and Control Practitioner, Markham Stouffville
Hospital
Dr. Danny Chen, Infectious Disease Specialist, York Central Hospital
Ms. Donna Moore, Manager, Infection Prevention and Control, York Central Hospital
The panelists were asked to:
•
•
•
Share specific successes and challenges regarding IPAC and their impact on quality
and/or patient flow in their hospital.
Describe a specific initiative(s) that their organization has undertaken to better
understand IPAC and strategies to manage care in the emergency department for
patients requiring isolation precautions.
Considering the earlier discussion:
o What actions might make a difference? Describe what changes would be
needed.
o What would require more time and resources to address? Why?
Below is a summary of the initiatives, successes and challenges indentified by the panelists:
•
•
•
•
•
Early screening, ideally at triage, is an important step to limit contact exposure from
infected or colonized individuals presenting at the ED. Early identification of patients for
whom follow-up testing or additional precautions is key. The use of a specialized unit to
provide streamlined admission can improve patient flow.
Developing and implementing standardized tools/signage that is more visible to staff
improves adherence to IPAC best practices. Visual notification on charts helps ensure
additional precautions are followed both in the ED and once the patient is admitted.
Continuous quality improvement methodologies should be applied to IPAC practices
within hospitals. The use of kaizen events and other LEAN methodologies can help
identify solutions to current challenges. Reporting IPAC performance can help staff
identify issues early and allow them to take pride in successes.
IPAC programs need to be supported by leadership to ensure the IPAC expertise is
available to other health care workers and that they are able to work closely with staff in
the ED to provide expertise on a 24/7 basis.
Technology should be used whenever possible to support IPAC. Active screening can
be built into the admissions process. Electronic prompts can alert staff when individuals
require testing and/or notify them of the additional precautions required.
6
NEXT STEPS / OUR COMMITMENT SURVEY
At the conclusion of the discussion, each participant was asked to reflect upon three key
questions in support of advancing IPAC within their own organization and in collaboration with
the LHIN. Participants were asked:
1. What would you say were the top three learnings from today?
2. Please identify what specific opportunities exist to advance infection prevention and
control to drive improvements in Emergency Department flow and length of stay:
a. Within your hospital
b. Across the LHIN
Central LHIN thanks Collaborative participants for their thoughtful feedback and participation.
Below is a summary of the key themes derived from review of written comments from the
participants:
Knowledge Transfer and Education
•
Ongoing provider and patient education is critical to raise awareness of IPAC best
practices, particularly when additional precautions are required to help limit the
introduction and transmission of infectious diseases within the hospital and from the
hospital to other settings.
Early Testing
•
Screening for infections early can reduce rates of infection transmission, and ensure the
accurate provision of IPAC in both positive and negative infection and colonization
cases. Central LHIN hospitals report success with screening initiatives at triage, and as
illustrated by the implementation of molecular testing at NYGH, early testing can
decrease patient length of stay.
Use of Visual Tools
•
Visual tools help communication within the organization and allow staff to easily identify
patients requiring additional precautions as well as the specific precautions needed.
Fact-sheets and print-outs for staff at the time of admission, as well as visual markers on
patient charts are examples of tools that have worked successfully in Central LHIN
hospitals.
Communications – Internal and External
•
Effective IPAC requires a team-based approach and good communication between team
members, within the organization and between organizations. Sharing data with
employees helps staff understand current challenges and acknowledge successes,
leading to improved performance. Dialogue between organizations such as long-term
care homes and hospitals can help with the transfer of patients between health service
7
providers ensuring individuals who require screening or additional infection precautions
are identified at the time of registration.
Leveraging Technology
•
Using technology to track patients who are infected or colonized can improve the
identification and appropriate management of clients during their stay, ensure they
receive the appropriate additional precautions, and help identify when additional
precautions have been discontinued to improve patient flow.
GOING FORWARD
The Advancing Infection Control Best Practices in the Emergency Department Quality
Collaborative provided important context regarding the role infection precautions and isolation
play in patient flow and length of stay in the ED.
Presenters and panelists agreed that while changing practices for infection prevention and
control can be challenging because of existing hospital infrastructure, creative strategies relating
to bed management, early diagnostics/screening and improved communications between
hospitals and long-term care homes, among others, can be employed to achieve improvements.
As a key next step, Central LHIN staff will work with hospitals to better understand the specific
impact of infection prevention and control additional precautions at each organization as it
relates to ED length of stay and flow.
This report and its key themes is a component of the Central LHIN Quality Action Plan. In
addition to being shared with all collaborative participants, the final report will be provided to
other key stakeholders and will also be posted on the Central LHIN website.
8
1
Katz, Kevin. "Emergency Department Flow and Infection Prevention and Control." Advancing Infection
Prevention and Control Best Practices in the Emergency Department. Central Local Health Integration Network.
York Central Hospital, North York, Ontario. 13 Dec. 2011.
2
Public Health Ontario. Provincial Infectious Diseases Advisory Committee on Infection Prevention and Control.
Annex B: Best Practices for Prevention of Transmission of Acute Respiratory Infection In All Health Care Settings.
Public Health Ontario, 2010. Web. 13 Jan. 2012.
3
Volkening, Grace. "Promoting Infection Prevention and Control Best Practices" Advancing Infection Prevention
and Control Best Practices in the Emergency Department. Central Local Health Integration Network. York Central
Hospital, North York, Ontario. 13 Dec. 2011.
4
Vearncombe, Mary. Management of Carbapenem-Resistant Enterobacteriacae (CRE) In All Health Care Settings.
Provincial Infectious Diseases Advisory Committee on Infection Prevention and Control. Aug. 2011. Web. 13 Jan.
2012.
5
Katz, Kevin. "Emergency Department Flow and Infection Prevention and Control." Advancing Infection
Prevention and Control Best Practices in the Emergency Department. Central Local Health Integration Network.
York Central Hospital, North York, Ontario. 13 Dec. 2011.
6
Ibid.
7
Drews, Stephen. Raboud, Janet, Katz Kevin. No Room at the Inn: Fever and Respiratory Illness Precautions and
the Placement of Patients within an Ontario Acute Care Institution. Infect Control Hosp Epidemiol. 28 Jan. 2007.
8
Ibid.
9
Ng, Wil. Katz, Kevin. Too Close for Comfort: Strategy for Screening MRSA Contacts. Society for Healthcare
Epidemiology of America. Dallas. 2001.
9