- Email: [email protected]
Infection control practices in Canadian hospitals
control ho J. Loss, M.D., D.E.C.H., M. Trotman, B.Sc. Ottawa, Ontario, Canada
F.R.C.P.(C),
prrnctices
in
IS
F.A.C.P.M.
Infection control is defined as the medical specialty or field dedicated to the prevention and management of infections in hospitals and the optimization of patient care.’ For well over a decade the amount of activity in infection control has been increasing in Canada and elsewhere. This has been especially true in the United States, where initiatives taken by the Centers for Disease Control (CDC) have resulted in the establishment and growth of infection control programs. In Canada, infection control activities in hospitals have been established in some centers since the early 1970s. With the specification of infection control requirements by the Canadian Council on Hospital Accreditation (CCHA) in 1975, the number of hospitals with programs has increased. In order to gauge the amount and nature of this activity the Bureau of Infection Control (BIC) of the Laboratory Centre for Disease Control, with the assistance of Statistics Canada, conducted a national survey in late 198 1 and early 1982. The specific objectives of the survey, sent to every hospital listed with Statistics Canada, were: first, to gather baseline information on infection control programs and practices in Canadian hospitals and, second, to determine training background and requirements of Canadian ICPs. This report will deal only with the infection control programs and practices. METHODS
A questionnaire was mailed to the administrators of all 1239 institutions defined by From the Bureau of Infection Control, Laboratory Disease Control, Health and Welfare Canada.
Centre for
Reprint requests: Dr. J. Losos, Director, Bureau of Infection Control, Laboratory Centre for Disease Control, Tunney’s Pasture, Ottawa, Ontario, KlA OL2, Canada
Statistics Canada as hospitals in this country. The administrator was asked to answer several specific questions and pass the rest of the questionnaire to the ICP(s). If no ICP was on the staff, the administrator was requested to return the questionnaire to the BIC. Questionnaires were sent in October of 1981. Hospitals were given 5 weeks to respond. Any who had not answered by then were sent a mailed letter requesting a response. An additional 5 weeks was given before a telephone reminder was made to nonrespondents. Questionnaires were preceded and data were entered into Statistics Canada computers for analysis in February 1982. RESULTS
The overall response rate was 87.5% (1084 hospitals). Response from individual provinces and territories varied from 72.0% in the northwest territories to a high of 96% in Nova Scotia. The response rate was high from all categories of hospitals, especially those classified as general hospitals of 100 beds or more, teaching, and pediatric hospitals (96% response). Of the responding sample, 55% of 1084 hospitals were accredited by the CCHA; 92.6% of hospitals classified as general (>lOO beds), teaching, or pediatric were accredited. Existence
of infection
control
programs
Sixty-three percent of hospitals responded that they have an infection control program of some nature by their own definition in their hospital. This was especially true of larger institutions and teaching and pediatric centers (Table 1), where 95.1% of hospitals with > 199 beds have programs (p < 0.0001). Qf responding hospitals that were accredited, 94% stated that they have an infection control 289
he~can
290
Loses and Tvotman
Joiirnal of
INFECTION CONTROL
Table 1. Respondents
Infedien
programs,
The majority of Canadian hospitals in Canada carry out surveillance of nosocomial infection. This is especially true of larger general, teaching, and pediatric hospitals (96.7% affirmative response). Type of surveillance varied considerably (Table 3). Approximately 50% of respondents for hospitals with >200 beds stated they did total surveillance. Hospitals with ~100 beds and rehabilitation and extended care institutions reported that they performed periodic or partial surveillance more commonly than total (p < 0.01). Of accredited acute care hospitals with >200 beds, 56.7% had full-time ICPs. However, only 25 hospitals (17%) with >300 beds had more than one ICP, a number suggested as necessaryto do effective surveillance and run a comprehensive infection control program. Of ICPs who were full-time employees in their positions, 53.7% did total prospective surveillance in their hospitals. Of ICPs who were full-time hospital employees but had other duties to perform, 34% did periodic surveillance of selective infection sites and services. Sources of information used for surveillance purposes also varied considerably. The most commonly utilized were microbiology laboratory report forms and infection report forms (Table 4). Most ICPs (77.3%) spend less than 20% of their time calculating infection rates and doing simple statistics, and 76.8% stated that they spend less than 20% of their time teaching infection control. Of respondents who stated that there was an infection control program in their hospital, 82.3% had a written set of guidelines for practice. Guidelines produced elsewhere were used by 23.3%, and 66.3% stated that they used set definitions relevant to infection control; 4.3% of ICPs claimed to use no documents of any kind.
with infection control by type and size of hospital Respondents with programs
Classification of hospital
Respondents (No.)
General 1-49 beds 50-99 beds 100-I 99 beds 200-299 beds a300 beds Teaching Pediatric Other specialty Rehabilitation Extended care Other public Private Federal Total
347 131 112 64 ai 71 9 18 17 109 8 40 105 1,112*
No.
%
170 115 95 62 75 69 0 11 14
49 0
20 714
*Some hospitals had more than one ICP responding hospitals responding was 1084
878 84.8 96.9 92.6 972 888 61 1 a23 65.1 0 100 19.0 64.2
Total number of
program; 81 .O% stated that they have a person designated as an ICP on staff. For nonaccredited institutions, 33.8% said they have a program; 29% have staff members designated as ICPs (difference significant at p < 0.000 1). The majority of ICP positions were created recently in Canadian hospitals. According to respondents who answered the survey question on date of establishment of the ICP position in their hospitals, three (0.6%) had been in existence from 1950 to 1955; 35.4% began between 1971 and 1975, but 45.2% began between 1976 and 1981 after the promulgation of CCHA requirements in infection control in 1975. Infection
control
committess
Of respondents, 61.8% stated that an infection control committee was formed in their hospital. Membership on the committees was varied and multidisciplinary (Table 2). Membership on some infection control committees included microbiologists, other laboratory staff, employee health nurses, operating room supervisors, dietary personnel, and others. Medical Officers of Health were represented on committees only 55.9% of the time in larger institutions and only 36.9% of the time in hospitals with ~299 beds (p < 0.0001).
Need
control
mttiaes
fer
Of the 656 ICPs who were respondents to this survey, 90.5% stated there was a need for Canadian guidelines in infection control; 3.0% disagreed and 6.5% were indifferent to the matter. The stated need for guidelines was high in
Volume 12 Number 5
Infection control practices in Canadian hospitals
October, 1984
Table 2. Infection control committee membership
291
in different types and sizes of hospital % in general hospitals ~299 beds (N = 428)
% Overall (N = 688)
% in general hospitals 2300 (N = 74)
% in teaching and pediatric hospitals (N = 78)
Committee members
%
No.
%
No.
%
No.
%
No.
Medical staff Medical officer of health Pharmacy representative Housekeeprng representative Central supply representative
91.3 39.7 33.6 71.5
628 273 231 492
89.7 36.9 28.5 71.3
384 158 122 305
98 6 60.8 47.3 73.0
73 45 35 54
96.2 51.3 33.3 65.4
75 40 26 51
41.0
282
42.7
183
37.8
28
37.2
29
Other members on Infection control committees included microblologists, dietary personnel, and others
other laboratory staff, employee health nurses, operating
room supervisors,
Table 3. Surveillance performed in hospitals in Canada and % performing Extent of Surveillance % performing Classification of hospital
Sample size (No. of hospitals)
Total
Some services daily
General 1-49 beds 50-99 beds 1 OO-199 beds 200-299 beds >300 beds Teaching Pediatric Other specialty Rehabilitation Extended care Other public
152 106 88 62 70 69 8 10 13 67 0
15.1 22.6 43.2 53.2 54.3 50.7 12.5 40.0 7.7 23.9 0
6.6 10.4 13.6 14.5 17.1 13.0 62.5 0 0 7.5 0
Private Federal Total
3 15 663
0 20 0 32.6
0 6.7 11.1
accredited centers.
rehabilitation
and
extended
Some Some sites daily
3.3 5.7 9.1 4.8 14.3 13.0 12.5 0 77 10.4 0 0 0 0 7.5
care
DISCUSSION Very little published data exist on the infection control practices in Canadian hospitals. In 1970 Westwood surveyed 146 hospital administrators in Ontario and 45 hospital microbiologists across Canada. It is difficult to compare these surveys because sampling and methods were different. However, one gets the impression that the situation has improved in Canada since 1968. In Westwood’s survey, 54% of hos-
periodlcally
Some sites periodically
Total periodically
Other
34.9 30.2 25.0 17.7 17.1 157 0 20.0 46.1 22.4 0
36.8 33.0 20.4 16.1 12.8 17.4 12.5 0.0 46.1 22.4 0
27.6 32.1 17.0 11.3 11.4 8.7 12.5 30.0 7.7 29 8 0
5.3 11.3 6.8 4.8 8.6 17.4 25.0 20.0 7.7 17.9 0
33.3 13.3 25.2
33.3 20.0 25.3
33 3 40 0 21.7
0 6.7 9.8
SeWiCeS
pitals with ~100 beds in size did not have infection control programs, whereas in our survey only 40% did not. In Westwood’s sample, 58% of hospitals had no ICP on staff, whereas in our 1982 survey 42.2% of hospitals were in that position. Interestingly, 1% of ICPs were full time in the 1968 figures and 18.6% were full time in 1982. The high response rate of the BIC survey (87.5%) may reflect the growing interest in infection control by the health care system. Requirements of the CCHA have increased over the past decade.3, 4 These two factors to-
Amwcan
292
Journal oi
INFECTION CONTROL
Losos ar?d Trotman
Table 4. Information sources used for surveillance
Souross
% of respondents using
Microbiology laboratory reports Infection report sheets or forms Employee health service reports Ward rounds Daily nursing reports Postdischarge reports X-ray forms Autopsy reports Pharmacy, distributton of antibiotics Other
84.3 75.3 53.7 52 5 47 9 26 3 190 151 14 1 14 1
gether reflect a growing emphasis on infection control. Most larger Canadian general hospitals with >200 beds, teaching hospitals, and pediatric hospitals have infection control programs in place. As expected this is especially true of accredited institutions, which are more likely also to have an ICP than are nonaccredited centers (p < 0.0001). The situation is not the same in smaller institutions and extended care, private, and federal hospitals. Actual infection control practices are varied in Canadian hospitals. Many kinds of surveillance are carried out. Given the variety of institutions represented this is probably justifiably so. Periodic or selected surveillance was more commonly reported from centers in which infection control duties were only part of the responsibilities of one staff member who had less time for case finding. The availability of practitioners and the ratio of ICPs to beds do not reflect this perceived ability to establish comprehensive infection control programs even in hospitals where ICPs are stated to exist, inasmuch as one ICP per 250 beds is the recommended ratio.
The variety of surveillance information sources, the little time spent on teaching, and the variety of guidelines in use reflect a lack of direction in some of the infection control practices in Canada. This is emphasized by the finding that 90.5% of respondents to the survey stated a need for Canadian guidelines despite the availability of information resources from CDC in Atlanta and other sources. This is probably because the existing guidelines are not always adaptable to Canadian institutions (e.g., extended care) and Canadian hospitals often do not have adequate access to state-of-the-art information resources. It is not feasible for infection control to be limited only to the hospital setting to the exclusion of the surrounding community.” Patients with communicable diseases are admitted to hospitals and patients with infection, often nosocomial, are discharged into the community in a dynamic ecologic interplay. This link necessitates a close working relationship between community, clinical, and public health resources and the hospital. The relationship should be closer and more active than that reflected by only 50% of infection control committees having medical officers of health participating. References 1. Wenzel WP: Handbook of hospital-acquired infections, ed 1. Boca Raton, 1981, CRC Press Inc. 2. Westwood JCN: Current national patterns-Canada proceedings of the International Conference on Nosocomial Infections. Atlanta, 1970, Centers for Disease Control. 3. Canadian Council on Hospital Accreditation: Guide to hospital accreditation. Ottawa, 1977, The Council. 4. Canadian Council on Hospital Accreditation: Standards for accreditation of Canadian health care facilities. Ottawa, 1983, The Council. 5. Brachman PS: Keynote address of the Tenth Annual Educational Conference of the Association of Practitioners in Infection Control. San Diego, May 1983.
F.R.C.P.(C),
prrnctices
in
IS
F.A.C.P.M.
Infection control is defined as the medical specialty or field dedicated to the prevention and management of infections in hospitals and the optimization of patient care.’ For well over a decade the amount of activity in infection control has been increasing in Canada and elsewhere. This has been especially true in the United States, where initiatives taken by the Centers for Disease Control (CDC) have resulted in the establishment and growth of infection control programs. In Canada, infection control activities in hospitals have been established in some centers since the early 1970s. With the specification of infection control requirements by the Canadian Council on Hospital Accreditation (CCHA) in 1975, the number of hospitals with programs has increased. In order to gauge the amount and nature of this activity the Bureau of Infection Control (BIC) of the Laboratory Centre for Disease Control, with the assistance of Statistics Canada, conducted a national survey in late 198 1 and early 1982. The specific objectives of the survey, sent to every hospital listed with Statistics Canada, were: first, to gather baseline information on infection control programs and practices in Canadian hospitals and, second, to determine training background and requirements of Canadian ICPs. This report will deal only with the infection control programs and practices. METHODS
A questionnaire was mailed to the administrators of all 1239 institutions defined by From the Bureau of Infection Control, Laboratory Disease Control, Health and Welfare Canada.
Centre for
Reprint requests: Dr. J. Losos, Director, Bureau of Infection Control, Laboratory Centre for Disease Control, Tunney’s Pasture, Ottawa, Ontario, KlA OL2, Canada
Statistics Canada as hospitals in this country. The administrator was asked to answer several specific questions and pass the rest of the questionnaire to the ICP(s). If no ICP was on the staff, the administrator was requested to return the questionnaire to the BIC. Questionnaires were sent in October of 1981. Hospitals were given 5 weeks to respond. Any who had not answered by then were sent a mailed letter requesting a response. An additional 5 weeks was given before a telephone reminder was made to nonrespondents. Questionnaires were preceded and data were entered into Statistics Canada computers for analysis in February 1982. RESULTS
The overall response rate was 87.5% (1084 hospitals). Response from individual provinces and territories varied from 72.0% in the northwest territories to a high of 96% in Nova Scotia. The response rate was high from all categories of hospitals, especially those classified as general hospitals of 100 beds or more, teaching, and pediatric hospitals (96% response). Of the responding sample, 55% of 1084 hospitals were accredited by the CCHA; 92.6% of hospitals classified as general (>lOO beds), teaching, or pediatric were accredited. Existence
of infection
control
programs
Sixty-three percent of hospitals responded that they have an infection control program of some nature by their own definition in their hospital. This was especially true of larger institutions and teaching and pediatric centers (Table 1), where 95.1% of hospitals with > 199 beds have programs (p < 0.0001). Qf responding hospitals that were accredited, 94% stated that they have an infection control 289
he~can
290
Loses and Tvotman
Joiirnal of
INFECTION CONTROL
Table 1. Respondents
Infedien
programs,
The majority of Canadian hospitals in Canada carry out surveillance of nosocomial infection. This is especially true of larger general, teaching, and pediatric hospitals (96.7% affirmative response). Type of surveillance varied considerably (Table 3). Approximately 50% of respondents for hospitals with >200 beds stated they did total surveillance. Hospitals with ~100 beds and rehabilitation and extended care institutions reported that they performed periodic or partial surveillance more commonly than total (p < 0.01). Of accredited acute care hospitals with >200 beds, 56.7% had full-time ICPs. However, only 25 hospitals (17%) with >300 beds had more than one ICP, a number suggested as necessaryto do effective surveillance and run a comprehensive infection control program. Of ICPs who were full-time employees in their positions, 53.7% did total prospective surveillance in their hospitals. Of ICPs who were full-time hospital employees but had other duties to perform, 34% did periodic surveillance of selective infection sites and services. Sources of information used for surveillance purposes also varied considerably. The most commonly utilized were microbiology laboratory report forms and infection report forms (Table 4). Most ICPs (77.3%) spend less than 20% of their time calculating infection rates and doing simple statistics, and 76.8% stated that they spend less than 20% of their time teaching infection control. Of respondents who stated that there was an infection control program in their hospital, 82.3% had a written set of guidelines for practice. Guidelines produced elsewhere were used by 23.3%, and 66.3% stated that they used set definitions relevant to infection control; 4.3% of ICPs claimed to use no documents of any kind.
with infection control by type and size of hospital Respondents with programs
Classification of hospital
Respondents (No.)
General 1-49 beds 50-99 beds 100-I 99 beds 200-299 beds a300 beds Teaching Pediatric Other specialty Rehabilitation Extended care Other public Private Federal Total
347 131 112 64 ai 71 9 18 17 109 8 40 105 1,112*
No.
%
170 115 95 62 75 69 0 11 14
49 0
20 714
*Some hospitals had more than one ICP responding hospitals responding was 1084
878 84.8 96.9 92.6 972 888 61 1 a23 65.1 0 100 19.0 64.2
Total number of
program; 81 .O% stated that they have a person designated as an ICP on staff. For nonaccredited institutions, 33.8% said they have a program; 29% have staff members designated as ICPs (difference significant at p < 0.000 1). The majority of ICP positions were created recently in Canadian hospitals. According to respondents who answered the survey question on date of establishment of the ICP position in their hospitals, three (0.6%) had been in existence from 1950 to 1955; 35.4% began between 1971 and 1975, but 45.2% began between 1976 and 1981 after the promulgation of CCHA requirements in infection control in 1975. Infection
control
committess
Of respondents, 61.8% stated that an infection control committee was formed in their hospital. Membership on the committees was varied and multidisciplinary (Table 2). Membership on some infection control committees included microbiologists, other laboratory staff, employee health nurses, operating room supervisors, dietary personnel, and others. Medical Officers of Health were represented on committees only 55.9% of the time in larger institutions and only 36.9% of the time in hospitals with ~299 beds (p < 0.0001).
Need
control
mttiaes
fer
Of the 656 ICPs who were respondents to this survey, 90.5% stated there was a need for Canadian guidelines in infection control; 3.0% disagreed and 6.5% were indifferent to the matter. The stated need for guidelines was high in
Volume 12 Number 5
Infection control practices in Canadian hospitals
October, 1984
Table 2. Infection control committee membership
291
in different types and sizes of hospital % in general hospitals ~299 beds (N = 428)
% Overall (N = 688)
% in general hospitals 2300 (N = 74)
% in teaching and pediatric hospitals (N = 78)
Committee members
%
No.
%
No.
%
No.
%
No.
Medical staff Medical officer of health Pharmacy representative Housekeeprng representative Central supply representative
91.3 39.7 33.6 71.5
628 273 231 492
89.7 36.9 28.5 71.3
384 158 122 305
98 6 60.8 47.3 73.0
73 45 35 54
96.2 51.3 33.3 65.4
75 40 26 51
41.0
282
42.7
183
37.8
28
37.2
29
Other members on Infection control committees included microblologists, dietary personnel, and others
other laboratory staff, employee health nurses, operating
room supervisors,
Table 3. Surveillance performed in hospitals in Canada and % performing Extent of Surveillance % performing Classification of hospital
Sample size (No. of hospitals)
Total
Some services daily
General 1-49 beds 50-99 beds 1 OO-199 beds 200-299 beds >300 beds Teaching Pediatric Other specialty Rehabilitation Extended care Other public
152 106 88 62 70 69 8 10 13 67 0
15.1 22.6 43.2 53.2 54.3 50.7 12.5 40.0 7.7 23.9 0
6.6 10.4 13.6 14.5 17.1 13.0 62.5 0 0 7.5 0
Private Federal Total
3 15 663
0 20 0 32.6
0 6.7 11.1
accredited centers.
rehabilitation
and
extended
Some Some sites daily
3.3 5.7 9.1 4.8 14.3 13.0 12.5 0 77 10.4 0 0 0 0 7.5
care
DISCUSSION Very little published data exist on the infection control practices in Canadian hospitals. In 1970 Westwood surveyed 146 hospital administrators in Ontario and 45 hospital microbiologists across Canada. It is difficult to compare these surveys because sampling and methods were different. However, one gets the impression that the situation has improved in Canada since 1968. In Westwood’s survey, 54% of hos-
periodlcally
Some sites periodically
Total periodically
Other
34.9 30.2 25.0 17.7 17.1 157 0 20.0 46.1 22.4 0
36.8 33.0 20.4 16.1 12.8 17.4 12.5 0.0 46.1 22.4 0
27.6 32.1 17.0 11.3 11.4 8.7 12.5 30.0 7.7 29 8 0
5.3 11.3 6.8 4.8 8.6 17.4 25.0 20.0 7.7 17.9 0
33.3 13.3 25.2
33.3 20.0 25.3
33 3 40 0 21.7
0 6.7 9.8
SeWiCeS
pitals with ~100 beds in size did not have infection control programs, whereas in our survey only 40% did not. In Westwood’s sample, 58% of hospitals had no ICP on staff, whereas in our 1982 survey 42.2% of hospitals were in that position. Interestingly, 1% of ICPs were full time in the 1968 figures and 18.6% were full time in 1982. The high response rate of the BIC survey (87.5%) may reflect the growing interest in infection control by the health care system. Requirements of the CCHA have increased over the past decade.3, 4 These two factors to-
Amwcan
292
Journal oi
INFECTION CONTROL
Losos ar?d Trotman
Table 4. Information sources used for surveillance
Souross
% of respondents using
Microbiology laboratory reports Infection report sheets or forms Employee health service reports Ward rounds Daily nursing reports Postdischarge reports X-ray forms Autopsy reports Pharmacy, distributton of antibiotics Other
84.3 75.3 53.7 52 5 47 9 26 3 190 151 14 1 14 1
gether reflect a growing emphasis on infection control. Most larger Canadian general hospitals with >200 beds, teaching hospitals, and pediatric hospitals have infection control programs in place. As expected this is especially true of accredited institutions, which are more likely also to have an ICP than are nonaccredited centers (p < 0.0001). The situation is not the same in smaller institutions and extended care, private, and federal hospitals. Actual infection control practices are varied in Canadian hospitals. Many kinds of surveillance are carried out. Given the variety of institutions represented this is probably justifiably so. Periodic or selected surveillance was more commonly reported from centers in which infection control duties were only part of the responsibilities of one staff member who had less time for case finding. The availability of practitioners and the ratio of ICPs to beds do not reflect this perceived ability to establish comprehensive infection control programs even in hospitals where ICPs are stated to exist, inasmuch as one ICP per 250 beds is the recommended ratio.
The variety of surveillance information sources, the little time spent on teaching, and the variety of guidelines in use reflect a lack of direction in some of the infection control practices in Canada. This is emphasized by the finding that 90.5% of respondents to the survey stated a need for Canadian guidelines despite the availability of information resources from CDC in Atlanta and other sources. This is probably because the existing guidelines are not always adaptable to Canadian institutions (e.g., extended care) and Canadian hospitals often do not have adequate access to state-of-the-art information resources. It is not feasible for infection control to be limited only to the hospital setting to the exclusion of the surrounding community.” Patients with communicable diseases are admitted to hospitals and patients with infection, often nosocomial, are discharged into the community in a dynamic ecologic interplay. This link necessitates a close working relationship between community, clinical, and public health resources and the hospital. The relationship should be closer and more active than that reflected by only 50% of infection control committees having medical officers of health participating. References 1. Wenzel WP: Handbook of hospital-acquired infections, ed 1. Boca Raton, 1981, CRC Press Inc. 2. Westwood JCN: Current national patterns-Canada proceedings of the International Conference on Nosocomial Infections. Atlanta, 1970, Centers for Disease Control. 3. Canadian Council on Hospital Accreditation: Guide to hospital accreditation. Ottawa, 1977, The Council. 4. Canadian Council on Hospital Accreditation: Standards for accreditation of Canadian health care facilities. Ottawa, 1983, The Council. 5. Brachman PS: Keynote address of the Tenth Annual Educational Conference of the Association of Practitioners in Infection Control. San Diego, May 1983.