Can Quebecs C' difficile experience help BC

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Can Quebecs C. difficile experience help BC?

• John Carsley MD
• PICNET Conference
• Richmond BC, April 3, 2009

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Outline

• A brief review of Quebecs C. diff incidence from
  1999 to now
• Diagnosis response to the 2003-2004 epidemic
• Overall (painful) lessons learned
• Quebecs surveillance system strengths
  weaknesses
• What I think BC should do

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Acknowledgements

• Dr. Colette Gaulin Québec Ministry of health
  social services
• Dr. Vivian Loo MUHC McGill University
• Diane Larin Montréal Public Health Dept.
• Rashpal Toor VCHA
• Some of this data was previously presented at the
  North East Region Epidemiology Meeting held in
  New Hampshire, October 2004

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Context

• Traditionally in Quebec, no PH involvement in
  hospital IC.
• Few HAs with regional IC committees
• In Montreal, McGill affiliated hospitals had
  regional IC committee
• Since 1998 legal obligation of health
  institutions to report any situation that might
  put patients at risk.
• Increasing problems with C. difficile in 2003
• Request for assistance from McGill IC control to
  Public Health in spring 2004

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Montreals first look in 2004

• Med-Echo database review
• hospitalisation register
• based on 13 periods April 1-March 31
• Dx et Rx based on summary sheet
• Period 1999 -2000 to 2003-2004

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Methods

• Acute care hospitals in Montreal (21)
• Psychiatric hospitals excluded
• Number of cases
• Average 1999-2003 compared with 2003-2004
• Colectomies associated with CDAD
• Deaths associated with CDAD
• Rate/1,000 hospitalisations

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CDAD in Montreal 1999-2003

• Av. of cases per annum 1999-20031169
• Number of cases in 2003-2004 4838
• Rates per 1000 admissions
• 1999 8.7
• 2000 8.7
• 2001 10.2
• 2002 14.2
• 2003 30.7

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Rates of CDAD /1000 admissions, observed
expected, 1999-2003, Montreal
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Trends in CDAD rates in 4 Montreal hospitals,
1999-2003
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CDAD in Montreal 2003

• Paediatric hospitals untouched
• Specialized institutes less affected
• Range of rates from 13 to 80/1000 admissions

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Complications of CDAD

• Colectomy
• Average colectomy rate 1999-2003 2.3
• Rate in 2003-2004 3.0
• Deaths
• Average 1999-2003 14,7
• 2003-2004 23,4

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Trends in CDAD rates by region, Québec 1999-2003
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Trends in CDAD rates/1000 admissions in 5 most
affected regions, Québec 1999-2003
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Epidemic response

• Summer 2004 through Winter 2005
• Media firestorm in Quebec
• Ministerial directive to HAs
• Visit each hospital (HA admin, PH, regional
  engineers)
• IC organization function
• Cleanliness, hygiene infrastructure
• Institutional IC support accountability
• Committee of investigation

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Results

• 10 million investment in IC staff,
  infrastructure, training surveillance
• Creation of regional IC coordination tables
• Mandatory system of non-nominal case by case CDAD
  reporting
• Monthly reports to central system (INSPQ)
• Quarterly public reports by region and hospital
  on INSPQ website
• Mandatory reports to Regional Boards monthly

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Findings of inspections

• Variety in IC practices and structure
• Deficiencies in almost all hospitals in all
  dimensions
• Decrepit infrastructure (at least in Montreal)
• Understaffing in IC and housekeeping personnel
• Some remarkable success stories

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Mechanisms of monitoring

• Hospital acquired CDAD only
• Starting 72 hours after admission (and less than
  4 weeks after discharge)
• Real time on-line case entry, but no later than
  30 days after the end of the fiscal period
• Data kept and analysed by INSPQ on contract with
  Health Ministry
• Public posting on Ministrys website every 4
  months

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Monitoring (continued)

• Initially, no real time access for Public Health
  Departments
• Late data entry by hospitals
• Difficulty in monitoring complications
• contribution to death very subjective
• Lack of clerical support for IC practitioners
• Apples oranges worries
• Analysed by size of hospital proportion of
  elderly patients

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Expansion of monitoring

• VRE and MSRA will be added to system shortly
• Montreal will pilot regional analysis of
  cardiovascular Sx infections and possibly
  orthopedic Sx infections

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Conclusions from Quebec

• Monitoring system works smoothly now
• Publishing nominal hospital data a political
  necessity and well accepted now by all players
• Centralized provincial system provides
  consistency of definition and analysis
• System must satisfy both IC and public health
  requirements
• Rapid data entry and real time access for PH

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• To paraphrase Thomas Jefferson
• The price of freedom from C. diff is eternal
  vigilance

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• Thank you very much
• Questions?