Characterization of Clostridium difficile Strains in British Columbia, Canada: A Shift from NAP1 Majority (2008) to Novel Strain Types (2013) in One Region.

Background. Clostridium difficile is a major cause of gastrointestinal illness. Epidemic NAP1 strains contain toxins A and B, a deletion in repressor tcdC, and a binary toxin. Objectives. To determine the molecular epidemiology of C. difficile in British Columbia and compare between two time points in one region. Methods. C. difficile isolates from hospital and community laboratories (2008) and one Island Health hospital laboratory (2013) were characterized by pulsed-field gel electrophoresis, PCR-ribotyping, toxin possession, tcdC genotype, and antimicrobial susceptibility. Results. In 2008, 42.7% of isolates had NAP1 designation. Hospital-collected isolates were associated with older patients and more NAP1 types. Unlike other isolates, most NAP1 isolates possessed binary toxin and a 19 bp loss in tcdC. All isolates were susceptible to metronidazole and vancomycin. A 2013 follow-up revealed a 28.9% decrease in NAP1 isolates and 20.0% increase in isolates without NAP designation in one region. Then, community-associated cases were seen in younger patients, while NAP types were evenly distributed. Isolates without NAP designation did not cluster with a PFGE pattern or ribotype. Conclusions. Evaluation of C. difficile infections within British Columbia revealed demographic associations, epidemiological shifts, and characteristics of strain types. Continuous surveillance of C. difficile will enable detection of emerging strains.

Determinants of healthcare workers' compliance with infection control procedures.

The purpose of this study was to assess determinants of healthcare worker (HCW) self-reported compliance with infection control procedures. A survey was conducted of HCWs in 16 healthcare facilities. A strong correlation was found between both environmental and organizational factors and self-reported compliance. No relationship was found with individual factors. Only 5% of respondents rated their training in infection control as excellent, and 30% felt they were not offered the necessary training. We concluded that compliance with infection control procedures is tied to environmental factors and organizational characteristics, suggesting that efforts to improve availability of equipment and promote a safety culture are key. Training should be offered to high-risk HCWs, demonstrating an organizational commitment to their safety.

Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines.

BACKGROUND: Traditional infection control policies have focused on engineering controls, specific protocols, and personal protective equipment (PPE). In light of the variable success in protecting health care workers (HCWs) from Severe Acute Respiratory Syndrome (SARS) in 2003, organizational and individual factors related to self-protective behavior in health care settings may also play an important role. METHODS: A critical review of the literature was conducted, directed at understanding what organizational and individual factors are important in protecting HCWs from infectious diseases at work. RESULTS: Organizational factors, such as a positive safety climate, have been associated with increased HCW adherence to universal precautions. There is some evidence that appropriate training of HCWs could be effective in changing HCW behavior if appropriate follow-up is applied. Very little research into these factors has been conducted with regard to preventing exposures to respiratory tract pathogens, but there was evidence from the SARS outbreaks that training programs and the availability of adequate PPE were associated with a decrease risk of infection. CONCLUSION: Variations in organizational and individual factors can explain much of the variations in self-protective behavior in health care settings. It is likely that these factors were also important determinants during the SARS outbreaks, but they have not been extensively studied.

Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature.

BACKGROUND: Severe Acute Respiratory Syndrome (SARS) was responsible for outbreaks in Canada, China, Hong Kong, Vietnam, and Singapore. SARS focused attention on the adequacy of and compliance with infection control practices in preventing airborne and droplet-spread transmission of infectious agents. METHODS: This paper presents a review of the current scientific knowledge with respect to the efficacy of personal protective equipment in preventing the transmission of respiratory infections. The effectiveness of infection control policies and procedures used in clinical practice is examined. RESULTS: Literature searches were conducted in several databases for articles published in the last 15 years that related to infection control practices, occupational health and safety issues, environmental factors, and other issues of importance in protecting workers against respiratory infections in health care settings. CONCLUSION: Failure to implement appropriate barrier precautions is responsible for most nosocomial transmissions. However, the possibility of a gradation of infectious particles generated by aerosolizing procedures suggests that traditional droplet transmission prevention measures may be inadequate in some settings. Further research is needed in this area.

Efficacy of common disinfectant/cleaning agents in inactivating murine norovirus and feline calicivirus as surrogate viruses for human norovirus.

BACKGROUND: The efficacies of disinfection by sodium hypochlorite, accelerated hydrogen peroxide (AHP), and quaternary ammonium compound (QUAT) commonly used in health care facilities were determined using the surrogate viruses murine norovirus (MNV-1) and feline calicivirus (FCV). METHODS: A virus suspension of known concentration (with or without a soil load) was deposited onto stainless steel discs under wet or dry load conditions and exposed to defined concentrations of the disinfectant/cleaning agent for 1-, 5-, or 10-minute contact time using the quantitative carrier test (QCT-2) method. Virus inactivation was determined by plaque assay. RESULTS: At an exposure time of 1 minute, sodium hypochlorite at 2,700 ppm was able to inactivate MNV-1 and FCV with a >5 log10 reduction. After 10 minutes, MNV-1 was inactivated by AHP at 35,000 ppm, whereas FCV was inactivated at 3,500 ppm. MNV-1 was not inactivated by QUAT at 2,800 ppm. A QUAT-alcohol formulation containing 2,000 ppm QUAT and 70% ethanol was effective in inactivating MNV-1 after 5 minutes, but resulted in only a <3 log10 reduction of FCV after 10 minutes. CONCLUSIONS: AHP and QUAT products were less effective than sodium hypochlorite for the inactivation of MNV-1 and FCV.

Impact of a mandated provincial hand hygiene program: messages from the field.

BACKGROUND: The British Columbia Provincial Hand Hygiene Working Group was formed in September 2010 and tasked with the development and implementation of a provincial hand hygiene (HH) program for health care. METHODS: As part of an evaluation of the provincial HH program, qualitative key informant interviews of program developers, senior administrators, and field workers were performed from December 2011 to March 2012 (phase 1) and again in April to June 2013 (phase 2). RESULTS: The following 5 broad themes were identified: (1) the provincial HH program became a platform for cooperation; (2) standardization (of HH audits and program components) strengthened and provided credibility to the provincial HH program; (3) quality results and good communication enabled a learning process that resulted in positive change management; (4) with ownership came pride and program success; and (5) management support and infrastructure is needed to sustain a positive culture change. CONCLUSION: Positive behavior change for HH can be achieved on a provincial scale through a program that is standardized, has mandated components, is well communicated, owned by the frontline workers, and receives sustained support from senior management.

Identifying the gaps in infection prevention and control resources for long-term care facilities in British Columbia.

BACKGROUND: Infection prevention and control (IPC) is a critical, although often neglected, part of long-term care (LTC) management. Little is known about what IPC resources are available for LTC and how that impacts patient care and safety. METHODS: One hundred eighty-eight LTC facilities were randomly selected out of all British Columbia facilities and surveyed using a validated survey tool. The tool was used to collect data regarding IPC resources grouped within 6 indices: (1) leadership, (2) infection control professionals (ICP) coverage, (3) policies and procedures, (4) support through partnerships, (5) surveillance, and (6) control activities. All components measured have been identified as key for an effective IPC program. Survey responses were used to calculate scores for IPC programs as a whole and for each of the 6 indices. RESULTS: Of 188 randomly selected facilities, 86 institutions participated. Facilities were compared by region, funding source, and ICP coverage. Overall, LTC facilities lacked IPC leadership, especially physician support. Having no dedicated ICP was associated with poorer scores on all indices. Only 41% of practicing ICPs had more than 2 years experience, and only 14% were professionally certified. Twenty-two percent of ICPs had additional roles within the institution, and 44% had additional roles outside of the institution. Thirty-five percent of institutions had no IPC dedicated budget. DISCUSSION: LTC institutions-with bed numbers exceeding those in acute care-represent an important aspect of health services. These data show that many LTC facilities lack the necessary resources to provide quality infection control programs.

Finding the gaps: an assessment of infection control surveillance needs in British Columbia acute care facilities.

BACKGROUND: This paper reports on an infection prevention and control surveillance survey of acute care facilities (ACFs) performed by the Provincial Infection Control Network of British Columbia. METHODS: A surveillance questionnaire was sent to all health care facilities that had access to an infection control professional. The questionnaire incorporated questions on organism-specific, disease-specific, and general surveillance activities. RESULTS: Questionnaires were returned from 47 of 51 (92%) of the ACFs surveyed. Participation in surveillance of methicillin-resistant Staphylococcus aureus-, vancomycin-resistant Enterococci-, and Clostridium difficile-associated disease ranged from 97% to 100%, but surveillance methodologies were inconsistent. Surgical-site infection surveillance did not correlate with the most commonly performed operations or with those procedures associated with higher morbidity and mortality from a postoperative infection. Considerable variation in data collection methods and case definitions was also identified. Surveillance for urinary tract infections, bloodstream infections, and ventilator-associated pneumonia was present in 28%, 51%, and 23% of responding ACFs, respectively. CONCLUSION: The current lack of a standardized surveillance system in British Columbia limits the ability of facilities to set appropriate benchmarks to assist in prioritizing and applying infection control interventions. The survey, however, has assisted in prioritizing implementation of surveillance activities and identifying the resources that would be required.

E-learning of infection control: it's contagious.

This article outlines the steps taken to deliver standardized infection control and occupational health training to all healthcare workers across a Canadian health authority, using an online module developed by a multidisciplinary team. The course had to meet a diverse variety of learner needs, be relevant to day-to-day practice, be accessible, as well as fulfill healthcare guidelines for both infection control and occupational health. The course was designed to be interactive and uses a wide variety of techniques to engage the learner such as video clips describing use of personal protective equipment, and drop-and-drag technology. Since implementation in 2006, the course has been endorsed by stakeholders and used in staff clinical orientations, for residents, for student placements, and for physicians as part of their hospital privileges, as well as healthcare workers across the health authority. Results of the user satisfaction survey (N=280) showed that the course was relevant and simple to navigate. Observations (N=117) of personal protective equipment donning and doffing of staff post-course showed that the module effectively transferred knowledge. Analysis of the interview results (N=50) suggested that making the course required would be seen as an incentive and visible sign of management commitment to safety. Development of the module was instructive both for the learners and the online infection control/education team. The implementation process provided insight into how best to deliver and evaluate healthcare content while ensuring that the product is user friendly. The process underscored the importance of engaging key stakeholders. With this course, learning of infection control principles has been made more efficient and enjoyable.

Personal protective equipment in health care: can online infection control courses transfer knowledge and improve proper selection and use?

We used observational evaluation to assess the ability of an online learning course to effectively transfer knowledge on personal protective equipment (PPE) selection and removal. During orientations for new hospital staff, 117 participants applied either airborne, droplet, or contact precautions in mock scenarios. Postcourse, all 3 scenarios demonstrated improvement in PPE sequence scores (P = .001); moreover, hand hygiene also was more frequent during both donning and doffing of PPE (P < .001).