Prevention of respiratory outbreaks in the rehabilitation setting

Corpus, Carla; Williams, Victoria; Salt, Natasha; Agnihotri, Tanya; Morgan, Wendy; Robinson, Lawrence; Maze Dit Mieusement, Lorraine; Cobbam, Sonja; Leis, Jerome A

Our rehabilitation centre reduced the number of bed closure days due to RV outbreaks to less than a third for two consecutive seasons through process changes that supported earlier initiation of transmission-based precautions for symptomatic patients, discouraged visitation by people with potentially infectious symptoms and made it easier for healthcare workers to stay home when potentially infectious. Despite evidence supporting IPAC practices to prevent nosocomial transmission of RV infection each RV season, the adoption of these practices following education alone is often suboptimal leading to preventable nosocomial outbreaks. There is a paucity of literature around using QI strategies to address these gaps and to our knowledge, none have been undertaken to prevent RV outbreaks in rehabilitation settings. In the paediatric population, nosocomial transmission has been shown to be prevented through screening of patients and cohorting nurses with positive children along with the use of transmission-based precautions. 5 In a population of stem cell transplant patients, universal use of surgical masks by healthcare providers was associated with a greater than 50% reduction in nosocomial RV infection. 8 Rehabilitation settings are environments conducive to nosocomial RV transmission due to the nature of the patient population, which is being mobilised daily in common spaces. Our approach was to better understand the barriers to adherence to IPAC practices within the rehabilitation context. We used epidemiological data to identify important triggers of outbreaks and then drilled down to understand the main drivers. For example, delays in testing and initiation of droplet and contact precautions were occurring due to lack of clarity around syndromic criteria which was addressed through systematic training. Lack of private rooms was an additional barrier noted by our staff, but our experience showed that earlier initiation of transmission-based precautions actually led to the same number of isolation-days presumably due to reduced nosocomial transmission. Finally, we uncovered a number of system problems that made it easier for staff to work while sick rather than staying home. These included the perceived pressure from human resources attendance management and the challenge in accessing OHS. Once these were addressed through Open access redevelopment of an OHS electronic software reporting programme, better reporting of illness was seen. These examples underscore the impact of process changes that are linked to the specific barriers to best practice rather than relying on education alone. 9 A striking finding in our study is that despite making it easier for staff to report to OHS, we observed no significant increase in the average number of missed work hours. One explanation for this finding is that the additional absences for staff staying home when potentially infectious was offset by a reduction in staff becoming infected while at work due to fewer encounters with infectious colleagues and fewer unprotected encounters with nosocomial RV cases. These data argue against the perception that staff staying home when symptomatic could increase staff shortages and should empower organisations to create similar models of care that make staying home when sick the easier thing to do. 10 Despite improvement in IPAC practices, we continued to observe sporadic nosocomial transmission of RVs at our facility. One potential explanation is that increase