Report to Rapport au: Ottawa Board of Health

Report to
Rapport au:
Ottawa Board of Health
Conseil de santé d’Ottawa
March 17, 2014
17 mars 2014
Submitted by
Soumis par:
Dr./ Dr Isra Levy,
Medical Officer of Health/Médecin chef en santé publique
Contact Person
Personne ressource:
Siobhan Kearns, Manager/Gestionnaire Environment & Health Protection/ Direction
de l'environnement et de la protection de la santé Ottawa Public Health/Santé publique
Ottawa 613-580-2424, ext./poste 23483, [email protected]
and
Carolyn Pim Associate Medical Officer of Health/ Médecin adjointe en santé publique
Ottawa Public Health/Santé publique Ottawa 613-580-2424, ext./poste 23484,
[email protected]
Ward: CITY WIDE / À L'ÉCHELLE DE LA
VILLE
File Number: ACS2014-OPH-EHP-0002
SUBJECT: UPDATE ON OTTAWA PUBLIC HEALTH’S OUTBREAK
MANAGEMENT STRATEGY FOR LONG-TERM CARE FACILITIES
OBJET:
RAPPORT SUR LA STRATÉGIE DE SANTÉ PUBLIQUE OTTAWA EN
MATIÈRE DE GESTION DES ÉCLOSIONS POUR LES
ÉTABLISSEMENTS DE SOINS DE LONGUE DURÉE
REPORT RECOMMENDATIONS
That the Board of Health for the City of Ottawa Health Unit receive this report for
information.
RECOMMANDATIONS DU RAPPORT
Que le Conseil de santé de la circonscription sanitaire de la ville d’Ottawa prenne
connaissance du présent rapport à titre d’information.
EXECUTIVE SUMMARY
Each year in Ottawa, there are approximately 60 respiratory and enteric outbreaks in
long-term care homes (LTCHs). In 2011, Ottawa Public Health (OPH) developed a
three-year Outbreak Management strategy aimed to reduce the number of outbreaks in
Ottawa’s 28 LTCHs. The strategy also aimed to mitigate the burden and negative
impacts of an outbreak by decreasing the duration of the outbreak, reducing the number
of residents affected, reducing the time between the onset of illness and the first contact
with OPH, and supporting LTCHs in the implementation of infection prevention and
control best practices and effective outbreak management measures.
Since the implementation of the strategy, OPH has shifted from a broad approach to
facility-specific approach to outbreak management. As part of this, OPH worked with
facilities to create a facility-unique profile, which has allowed OPH to identify the unique
infection prevention and control challenges of each facility and ensure educational
sessions meet site-specific needs. Although group education sessions are still being
offered, such as the Outbreak 101 workshops and a large annual Infection Prevention
and Control Forum, OPH also now provides individual facilities with one-on-one
education sessions on request.
Over the past three years, OPH has also improved communications with hospitals and
LTCH in an effort to reduce the time between the onset of illness and the first contact
with OPH. In the 2012/2013 season, facilities were offered, and used, a direct outbreak
reporting mechanism, enabling optimal response without delay.
Over the next two years, OPH plans to expand on the strategy by providing additional
supports to facilities that have higher than average number of outbreaks and
implementing components of the strategy in other institutions.
RÉSUMÉ
Chaque année à Ottawa, on compte une soixantaine d’éclosions de maladies
respiratoires et entériques dans les établissements de soins de longue durée (ESLD).
En 2011, Santé publique Ottawa (SPO) a élaboré une stratégie triennale de gestion des
éclosions visant à réduire leur nombre dans les 28 ESLD d’Ottawa. La stratégie visait
également à alléger le fardeau et les répercussions d’une éclosion en réduisant sa
durée, le nombre de résidents touchés et le délai entre l’apparition d’une maladie et le
premier contact avec SPO et en aidant les ESLD à mettre en œuvre des pratiques
exemplaires de prévention et de contrôle des infections et des mesures efficaces de
gestion des éclosions.
Depuis la mise en œuvre de la stratégie, SPO a délaissé une approche générale pour
adopter une approche de gestion des éclosions à l’échelle de chaque établissement.
Ainsi, SPO a travaillé avec les établissements à l’élaboration d’un profil qui leur est
propre. Santé publique Ottawa a ainsi pu déterminer les difficultés particulières
auxquelles ils faisaient face en matière de prévention et de contrôle des infections et
veiller à ce que les séances de sensibilisation répondent à leurs besoins. Même si des
séances de sensibilisation collectives sont encore offertes, par exemple les ateliers
Gestion des éclosions 101 et un grand forum annuel sur la prévention et le contrôle des
infections, SPO offre désormais aux établissements des séances de sensibilisation
individuelles sur demande.
Au cours des trois dernières années, SPO a également amélioré ses communications
avec les hôpitaux et les ESLD pour réduire le délai entre l’apparition de la maladie et le
premier contact avec SPO. Pendant la saison 2012-2013, les établissements ont utilisé
un mécanisme de déclaration directe des éclosions proposé par SPO, qui a permis une
intervention optimale et rapide.
Au cours des deux prochaines années, SPO entend étoffer la stratégie en offrant un
soutien supplémentaire aux établissements où le nombre d’éclosions est supérieur à la
moyenne et en mettant en œuvre certains volets de la stratégie dans d’autres
établissements.
BACKGROUND
On June 20, 2011, the Ottawa Board of Health received an oral presentation regarding
Ottawa Public Health’s (OPH) three-year Outbreak Management Strategy.
Subsequently, the Board received a progress report on January 21, 2013. This report
serves to provide further update on the strategy’s five broad components: capacity
assessment/gap analysis, educational support, stakeholder engagement, surveillance
and reporting, and program evaluation. The report also outlines next steps for
expanding the strategy.
The strategy aimed to reduce the number of outbreaks in Ottawa’s 28 Long-Term Care
Homes (LTCH), mitigate the burden and negative impacts of an outbreak by decreasing
the duration of the outbreak, reduce the number of residents affected, reduce the time
between the onset of illness and the first contact with OPH, and support LTCHs in the
implementation of infection prevention and control (IPAC) best practices and effective
outbreak management measures. Over the past three years, OPH has worked with
these facilities to improve the detection and management of outbreaks in LTCHs; and to
enhance communications, operations, and partnerships. While there have been
significant improvements in many areas, OPH continues to work with these facilities to
address their on-going challenges.
Approximately 60 outbreaks occur in Ottawa LTCHs every year. An outbreak is
declared when a disease occurs in excess of its expected frequency, or when cases are
clustered in space, time or in a particular population. The 2012/2013 season in Ottawa,
as in the rest of Ontario, was an exceptionally busy outbreak season with 88 reported
outbreaks, due, in part, to the significant effect of influenza A on the long-term care
population. The 2012/2013 outbreak season required enhanced capacity with support
from other OPH teams to ensure that all necessary services were provided to these
facilities. One positive outcome resulting from this challenging season is that additional
OPH staff have now been trained and have gained experience in outbreak
management.
Largely due to the resources and tools developed during the strategy, the exceptionally
busy 2012/2013 outbreak season did not present OPH with significant operational
issues or concerns outside the regular scope of outbreak management. Throughout the
2012/2013 season, outbreaks were consistently reported directly to an OPH outbreak
reporting phone line to ensure real-time reporting to OPH.
Application of the strategy’s five tenets contributes to attaining the overarching goal to
eliminate all outbreaks in the city of Ottawa, by mitigating the impact of outbreaks and
helping facilities navigate through their IPAC and outbreak management needs.
Progress on Outbreak Management Strategy
The five components of The Outbreak Management Strategy are outlined below. While
constraints outside of OPH’s control, such as the type of organisms circulating in any
given year and the virulence of these organisms, have precluded the elimination of
outbreaks in Ottawa, significant improvements to the management of outbreaks have
occurred across the city since the implementation of the strategy. These include the
development of resources, improved communication with facilities and stakeholders, as
well as the development of a transfer decision tool, which the Ministry of Health and
Long-Term Care used as a framework to develop a similar resident transfer tool.
Facility Profile and Capacity Assessment/Gap Analysis
A significant change in OPH’s approach to working with LTCH was a shift from a
generic approach to a facility-specific approach. As each facility is unique and the IPAC
challenges that they face are diverse, OPH created a profile for each facility, which
included a capacity assessment. This profile helped determine each facility’s outbreak
management readiness. Based on the capacity assessments, OPH was able to
determine IPAC and outbreak management needs for each facility. Facility-unique
education and resources, including one-on-one education sessions for these facilities
were developed. Moreover, in the third year of the strategy, OPH also conducted
environmental assessments of some facilities to enhance understanding of the IPAC
and outbreak management needs of those facilities. As part of the environmental
assessment, OPH reviewed IPAC issues related to housekeeping, general sanitation,
emergency planning, and use/storage of personal protective equipment in these
facilities.
Education Support
A component of the strategy was the development and enhanced provision of tailored
education and support for each facility’s unique IPAC needs. OPH also continued to
provide group education sessions, such as the Outbreak 101 workshops and a large
annual Infection Prevention and Control Forum. In 2013, in response to requests by
individual facilities, one-on-one education sessions, which provided customized
information and resources to a given facility based on its particular needs, were
introduced. This shift in educational strategy has resulted in more staff in each facility
being equipped with outbreak management information and knowledge. In 2013, 11
one-on-one education sessions were offered to LTCHs, with almost 250 staff attending
and additional sessions scheduled for 2014.
OPH has also developed and implemented an Outbreak Management Tool Kit, which is
a multi-faceted resource aimed to support LTCHs in the implementation of IPAC
practices. This kit provides front line staff with the necessary information and tools to
effectively and rapidly implement outbreak management interventions. For example, a
Transfer Decision Flowchart outlines key decisions in the transfer of residents between
acute care and LTCHs, facilitating smoother and more efficient resident transfers.
Recently, the Ministry of Health and Long-Term Care developed a similar resident
transfer tool for use by all health units in the province, and acknowledged OPH as a
significant contributor in the development of this resource.
Stakeholder Engagement
Communications with all relevant partners have been strengthened. As outbreaks in
one institution can have implications on other health services, such as hospitals and
Community Care Access Centre (CCAC), it is imperative that there are effective lines of
communication between all partners.
In 2013, OPH consulted with LTCHs to evaluate the effectiveness of the LTCH Liaison
Committee – which included representation from OPH, LTCHs, the Local Health
Integrated Network, the Regional Infection Control Network & CCAC - whose mandate
was to strengthen communication and share common concerns regarding IPAC issues.
Based on an analysis of these consultations, it is anticipated that the LTCH Liaison
Committee will evolve to a more efficient and goal oriented structure.
OPH has established regular communication with the acute care IPAC staff in order to
provide relevant information and reminders of outbreak management protocols during
peak season. Partnerships with LTCH have been strengthened by assigning a public
health inspector and a public health nurse to each facility to serve as an OPH pointcontact at these facilities. OPH also provides community partners with daily outbreak
status updates during outbreak season to strengthen communications among
stakeholders.
Reporting
OPH and the Champlain Community Care Access Centre (CCAC) have established an
outbreak hotline to communicate real time outbreak status updates via voicemail as
opposed to a weekly fax. This has enabled OPH to negotiate and develop transfer
recommendations more effectively, and has promoted timely and efficient repatriation of
residents from hospital to LTCHs, ultimately leading to reduced transfer and acute care
bed delays and reducing burden on the health care system.
Program evaluation
Continual iterative evaluation is performed in the program, and adjustments are made
based on this information. Most notably, OPH has conducted an evaluation of the
Outbreak Management Tool Kit with several LTCHs, has adjusted its education
sessions to provide facility-specific IPAC information and has replaced the LTCH
Liaison Committee with more effective means of communicating with the various
agencies.
Notable successes resulting from the implementation of the Outbreak Management
Strategy include strengthening the capacity of OPH and LTCH staff to implement IPAC
and outbreak management measures in the LTCHs; enhancing partnerships and
communication among key stakeholders; and most importantly, informing decisions
regarding repatriation of patients from hospitals to LTCH. The combination of these
successes has helped to alleviate a burden on the health care system.
DISCUSSION
Next Steps
In coming years, OPH will expand the strategy by providing supports to facilities that
have higher than average number of outbreaks, implementing components of the
strategy in other institutions, as well as strengthening internal capacity to meet the new
Public Health Funding and Accountability Agreement target for LTCH.
Additional supports for LTCH with higher than average outbreaks
On average, LTCHs report approximately two outbreaks per year. There are, however,
some facilities that tend to experience more outbreaks than others. Newer facilities are
typically designed with IPAC in mind while older facilities may have fewer or poorly
located hand washing sinks making hand hygiene more challenging. As well, older
facilities may have carpeting and upholstered furniture that are difficult to clean. In
addition, the physical layout of some resident spaces for example quad rooms, shared
bathrooms, and storage of clean and soiled equipment can contribute to IPAC
challenges. Larger institutions with large resident population are more susceptible to
outbreaks as more visitors enter the facility. OPH will work with these facilities in the
areas of education, ensuring compliance with LTCH legislation, ensuring all necessary
tools and communications are in place as well as encouraging these facilities to
promptly report outbreaks to OPH. In 2014, OPH will also reinforce to all facilities
information pertaining to the duty of LTCHs to report outbreaks to OPH according to the
Health Protection and Promotion Act.
New Public Health Funding and Accountability Agreement Target
The new Public Health Funding and Accountability Agreement includes a measure
regarding outbreaks in LTCHs. Specifically, OPH will be required to report on the
percentage of confirmed LTCH respiratory outbreaks where confirmation of
implementation of infection control measures was received within 24 hours of public
health notification. The target for this indicator is expected to be 100% compliance. OPH
will continue to work with these facilities with an aim to meet this target.
Expanding the Strategy into Other Institutions
Moving forward, OPH will continue to build on the successes of the three-year Outbreak
Management Strategy to expand these activities and resources to address IPAC
requirements in Retirement Homes. This aligns with the enacted regulations pertaining
to the application of the Retirement Homes Act, 2010, which now requires retirement
homes in Ottawa to develop an infection prevention and control program. This new Act
significantly lessens the differentiation between LTCHs and RHs. OPH plans to:

create a customized outbreak management tool kit for retirement homes


conduct environmental inspections of retirement homes
prioritize education for retirement homes

ensure a single point of contact (one public health inspector and one public
health nurse) for all retirement homes
The requirements within this new legislation carry with them challenges for OPH in both
resources and staffing capacity. To address these challenges, OPH will continue to
prepare well in advance of outbreak season and to ensure facility staff have the
information they need to prevent and control outbreaks.
In addition, OPH will work to strengthen existing partnerships with agencies such as the
Regional Infection Control Network, provincial LTCH inspectors, the Retirement Homes’
regulatory authority inspectors, the Public Health Ontario Laboratory, and acute care
hospitals.
LEGAL IMPLICATIONS
There are no legal impediments to receiving the information in this report.
RISK MANAGEMENT IMPLICATIONS
There are no risk management implications associated with this information report.
FINANCIAL IMPLICATIONS
There are no financial implications associated with this report.
ACCESSIBILITY IMPACTS
There are no accessibility implications to receiving this report.
TECHNOLOGY IMPLICATIONS
There are no technology implications associated with this report.
TERM OF COUNCIL PRIORITIES
The recommendations in this report support the 2010-2014 Term of Council Priorities
under “Healthy & Caring Communities”.
BOARD OF HEALTH STRATEGIC PRIORITIES
The recommendations in this report support the Board of Health Strategic Priority B5:
Reduce health risks related to preventable infectious and non-infectious diseases.
DISPOSITION
This report is for information. OPH will continue to implement the outbreak management
strategy for long-term care facilities.