C. difficile control: Handwashing practices lax at Quebec hospitals

Handwashing is one of the most important measures health care workers can take to prevent the spread of hospital-acquired infections.

• Handwashing in hospitals: How Quebec compares to other provinces
• More health data should be made public, Gaétan Barrette says

Yet — more than a decade after Quebec first faced an outbreak of Clostridium difficile so deadly and so rampant that it killed an estimated 1,900 people by late 2006 — most hospitals in Quebec still get a failing grade when it comes to that basic act of handwashing.

These premises should be zero risk,- Patient rights' advocate Paul Brunet

A six-month investigation by Radio-Canada's Enquête has found few hospitals where doctors and other health care personnel consistently wash their hands before and after making contact with a patient. 

That handwashing target is set at 80 per cent in Quebec's five-year ministerial action plan for 2015-2020 to prevent and control hospital-acquired infections.

Quebec patient rights' advocate Paul Brunet said there is no reason hospital staff aren't washing their hands 100 per cent of the time, before and after meeting each patient.

"These premises should be a zero risk," said Brunet.

However, Enquête found that the average rate of handwashing by health care workers before they came into contact with a patient was just over 42 per cent. After patient contact, that rate was 62 per cent.

Only 15 hospitals meet targets

Using data collected from access-to-information requests, Enquête compiled the results of handwashing audits supplied by 95 hospitals and other health care institutions across the province.

• In only three hospitals did the audits show health care personnel are meeting or surpassing that 80 per cent target for handwashing before coming in contact with a patient.  
• In only a dozen institutions did health care personnel meet or surpass that 80 per cent target for handwashing after a patient was seen.

Key handwashing moments 

Infection-control literature describes four key moments when health care staff must wash their hands:

1. Before coming into contact with the patient or their environment
2. Before procedures requiring sterilization
3. After any possible contact with body fluids
4. After contact with the patient or his environment

Most hospitals verify compliance with all four stages, but they focus most intensely on checking the first and last steps: handwashing before and after contact with patients.

Even after removing gloves, health care workers are supposed to wash their hands.

C. difficile: down but not out

Quebec hospitals have conducted repeated awareness campaigns about the importance of handwashing in the years since the 2004 outbreak of C.difficile forced them to take a hard look at infection control.

At least partly as a result of those campaigns, the rate of C. difficile-associated diarrhea has been on decline, hitting its lowest rate in five years in 2014-2015. 

Even at that, 3,453 cases were reported in 2014-2015.

Of those cases, 547 people died within 30 days of being diagnosed with a C. difficile infection, although the bacterial infection wasn't necessarily the cause of death in every case.

C. difficile rates in Quebec, 2004-2015

Note: Data from April 1 to March 31, except for 2004-2005: At that time, data was compiled from August to August. 4,315 represents the number of cases from August 2004 to March 2005. It should be noted that the total number of cases in the 12-month period from August 2004 - August 2005 was 6,350. As for death rates, data was only reported starting in August 2008.

Single-bed hospital rooms a key goal

In its five-year action plan to control hospital-acquired infections, the government outlines several key targets.

One of them is to eliminate hospital rooms with more than two beds and a shared washroom.

In Quebec, 29.6 per cent of acute-care beds are in single rooms. 

Nearly half of all hospital rooms are double occupancy.

The other 20.5 per cent of acute-care beds are in multi-bed wards.

These statistics date from September 2014 and do not take into account the MUHC's recent move to the new Glen campus, where all patients now have single rooms.)

Notes on the methodology of the Enquête investigation:

• The red reference line in our graph is set at 80 per cent: That is the target rate for handwashing before and after patient care, set out in the five-year ministerial action plan to control hospital-acquired infections.
• Access-to-information requests were sent in April 2015 to the 95 health-care institutions which report annually to the INSPQ their diarrhea rates associated with C. difficile.
• Due to health-care system restructuring that went into effect on April 1, 2015, a second set of access-to-information requests were made to certain of the new CISSS and CIUSSS, in order to ensure requests all went to the competent authorities.
• Enquête requested documents and minutes of discussions relating to handwashing audits from 2010 to June 2015. Audits conducted after June 2015 were not included in these findings.
• Hospitals did not compile observed handwashing "moments" in a single, consistent way. These differences are noted in the table.
• Enquête didn't have access to the methodology for each handwashing audit. Experts noted some audits were conducted secretly, so that health-care personnel didn't know they were being observed. Others were more open in their approach. These differences could skew the results.
• The sampling size of audits also varied widely: some were based on fewer than 100 observed handwashing "moments", others on thousands, observed over a longer period of time. This, too, has been noted in the tables.
• The number of wards audited varied greatly from one hospital to another.
• Close to a dozen hospitals undertook no handwashing audits for two or three years. Other hospitals consistently produce audit results every two months.
• Not all hospitals audit all staff. For example, the Montreal Cardiological Institute only provided data for its audit of nurses and nursing aides. Some hospitals included patients' visitors in their audits.
• Eight hospitals (listed below) only provided an overall average of handwashing compliance, without breaking down the practice into before-patient-contact and after-patient-contact "moments":
  • Royal Victoria Hospital (MUHC)
  • Montreal General Hospital (MUHC)
  • Montreal Chest Institute (MUHC)
  • Montreal Neurological Hospital (MUHC)
  • Maniwaki Hospital
  • Notre-Dame-du-Lac Hospital
  • Centre hospitalier du Pontiac
  • St-Jérôme Regional Hospital​
• Based on the data provided, Enquête could not produce a precise result for Lachine Hospital (MUHC).
• Based on 86 of the 95 hospitals which provided data for before-patient-contact and after-patient-contact handwashing, Enquête calculated a provincial average.

A word of warning, however: The average does not take into consideration the sampling size of each handwashing audit, so that it gives equal weight to a hospital which based its audit on a few dozen observations and one which based its audit on thousands of observations.