In September, Ontario’s 157 hospitals began publicly reporting their number of cases and rate per patient days of C. difficile-associated disease. As a large community hospital which experienced a serious outbreak of C. difficile, I applaud the government’s move toward greater public accountability and transparency.
While there has been much discussion within the hospital sector about the consistency and interpretation of data, definitions, death rates and the format of public reporting, in my view a recent article in a Thunder Bay newspaper summed up the debate very succinctly. It described public reporting simply as, “making sure that hospitals are completely up front with the public.” Doesn’t that get to the heart of the intent of public reporting? Ensuring that we, as hospitals, are open and transparent and that the public is fully informed about what’s happening within the walls of our organizations?
In 2007 Royal Victoria Hospital (RVH) in Barrie, Ontario experienced a 5-month C. difficile outbreak. A spike in cases was revealed during month-end analysis and within a week we had convened the Incident Management Team; established an Operations Task Force; requested the assistance of an expert infection control team from University Health Network; and developed an aggressive 50-point Action Plan of control measures.
RVH, with the full support of its Board of Directors, also opted to communicate with hospital staff and the community at large immediately. At the time there were few hospitals who had publicly declared an outbreak and it wasn’t yet an issue on the Ontario media’s radar. We really didn’t know how our community would react, but we knew full disclosure was the right thing to do. Transparency, honesty and openness were principles that guided our ‘public reporting’ throughout the outbreak and subsequent death chart review.
Throughout the 5-month outbreak we communicated frequently with stakeholders. Upon learning the results of a chart review of all C. difficile patients who died at the hospital during the previous six months, I personally called the families of every patient whose death was linked to the disease. In collaboration with the Simcoe Muskoka Medical Officer of Health, Dr. Charles Gardner; Dr. Michael Gardam, director of infection prevention and control at University Health Network; and RVH Chief of Staff Dr. Michael Murray, we also held a news conference to convey the results to our community.
In the end, the media – both local and national — covered the story fairly and accurately, while our community remained supportive of RVH’s transparent approach. Last spring RVH added another measure of accountability by voluntarily posting our incidence of hospital-associated C. difficile, along with Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE).
Having weathered a difficult storm, Royal Victoria Hospital is a different organization today than it was in 2007. The ‘new normal’ means we not only track C. difficile cases on a daily basis, but the hospital-wide situation is assessed daily. This hospital-wide, electronic early warning system allows all departments to be proactive and ensure the response at the unit level begins quickly, and does not wait for a significant problem to develop before we take aggressive action. Antibiotic use, an important risk factor for C. difficile, is rigorously monitored and managed. There has been tremendous uptake by our medical staff, particularly orthopaedic surgeons. For example, since the outbreak the use of the antibiotic clindamycin has dropped by 62 per cent.
RVH’s Environmental Services department has been bolstered and housekeeping practices have been enhanced, including the switch to more effective – albeit costly – cleaning products.
The most aggressive change has been in the area of education. Since the outbreak, all staff, physicians and volunteers have undergone intensive re-education on hand hygiene and the proper use of protective equipment. Intermittent audits are conducted on patient care units, and the hospital’s mantra has become: “Just clean your hands.” Of course, there is a significant cost to this. Ongoing control measures cost RVH approximately $500,000 annually and that’s money that must be found in a global budget that is facing a deficit in 2008/’09. However, lowering our vigilance on this ‘new normal’ is not an option.
So what will the impact of public reporting be? What will people do with the information? There’s much debate about whether public reporting will change patient behaviour, but it has already changed hospitals’ behaviour and allows us to further instill a culture of safety and accountability within our organizations. It is said that “if you can’t measure it, you can’t manage it.” Ontario’s public reporting forces all hospitals to measure their rates of C. difficile on a daily basis, something that was not happening in a consistent manner. Now the patients entrusted to our care can be assured, if we know something is happening inside our hospital, not only are we are doing something about it, but we’re making them aware of it. Only then are we truly ‘walking the talk’ of patient safety.