All rights reserved. No part of this work covered by the copyright hereon may be reproduced or used in any form or by any means – graphic, electronic, or mechanical including photocopying, recording, taping, or information storage and retrieval
systems – without written permission of the author.
ii
The views expressed in this paper are those of the author and do not necessarily reflect the official policy, position, or views of the British Columbia Institute of Technology (BCIT),
the Environmental Health Program, or its Faculty.
iii
Abstract
The process of disease transmission in community based health care settings has been
thoroughly examined and findings from this research have encouraged the creation of guidelines to
minimize the risk of health care associated infections within these facilities. To date however,
monitoring of the implementation of these recommendations by public health organizations has been
sparse. Completed in Vancouver, British Columbia during the winter of 2010/11, this study assessed the
degree of infection control that is practiced at clinics located in areas of ‘low-medium’ socioeconomic
status – Vancouver, versus those located in areas of ‘high’ socioeconomic status – Westside Vancouver.
Data was collected by visual observation and surveying of health care providers at 25 clinics located in
Westside Vancouver and 35 clinics located in the remainder of Vancouver. Each clinic was assessed by
means of 15 universal infection control criteria. The scores (x/15) of the clinics were aggregately graded
in each region by converting to mean percentage and then analyzed by both descriptive and inferential
statistics. The mean scores (%) obtained for clinics located in Westside Vancouver and the remainder of
Vancouver were 72.8% and 72.4% respectively. Assuming normality in a two-sample Aspin-Welch
Unequal-Variance T-test, it was concluded that there is no statistically significant difference between
the level of infection control demonstrated at clinics located in regions of varying socioeconomic status
(P = 0.902624). While scores were consistent between socioeconomic regions, the mean scores do
suggest infection control deficiencies and room for improvement in these settings regardless of region.
In addition to the issues observed amongst individual clinics, there is a need for more consistency.
Poorly performing clinics must raise their standards to those observed amongst the study’s stronger
performers. Recognizing the importance of preventive medicine may finally have reached a level where
infection prevention and control in medical clinics ought to switch from unregulated recommendations
to a set of regulated and standardized best practices.
iv
Table of Contents Abstract ........................................................................................................................................................ iii
List of Tables, Figures, and Appendices ........................................................................................................ v
Introduction ................................................................................................................................................. vi
Literature Review ....................................................................................................................................... viii
Pathogen survival in the medical clinic environment .............................................................................. ix
Disease transmission in the medical clinic environment .......................................................................... x
The high-risk nature of the medical clinic environment ......................................................................... xii
Research lays the foundation for infection control program planning .................................................. xiv
Purpose of the Study ................................................................................................................................... xv
Experimental Procedure ............................................................................................................................. xvi
Materials and clinic selection.................................................................................................................. xvi
Development of grading tool ................................................................................................................ xviii
Inclusion and exclusion criteria ................................................................................................................ xx
Pilot study ................................................................................................................................................ xx
Results and Analysis .................................................................................................................................... xxi
Research results and analysis ............................................................................................................... xxiii
Interpretation of data ........................................................................................................................... xxvi
1. Socioeconomic profiles of Vancouver’s Local Health Areas (LHAs) based on information collected for the income measures of families in the Statistics Canada 2005 Census (BC Stats, 2009).
2. Summary of descriptive (Microsoft Excel) and inferential (NCSS) statistics calculated using statistical computer software.
3. Summary of combined results for individual infection control criteria.
Figures
1. Map of Local Health Areas (LHAs) in Vancouver, as defined by the BC Ministry of Health (BC Stats, 2009). Socioeconomic regions were divided into Westside Vancouver and the remainder of Vancouver.
2. Graphical representation of combined results displayed as percentage (%) of clinics practicing individual infection control criteria.
Appendices
A. Assessment of individual criteria in regions of low-medium socioeconomic status by descriptive statistics using Microsoft Excel Software.
B. Assessment of individual criteria in regions of high socioeconomic status by descriptive statistics using Microsoft Excel Software.
C. Income Measures of Vancouver Local Health Areas as described by BC Stats 2009. D. Results printout of Two Sample T-test run using NCSS. Due to the results of the tests of
assumption, the equal variance t-test was used to interpret the data. E. Graphical results printout of Two Sample T-test run using NCSS.
vi
Introduction
Globalization has put the spread of infectious disease at the forefront of public health.
However, as the field of public health expands, the basic control measures must not be overlooked. The
transfer of potentially harmful agents across borders and continents is an emerging problem, but the
control of local, endemic disease is still the greatest concern. Higher standards for sanitation, complex
surveillance and monitoring techniques, vaccination programs, and improvements with public health
policy have all contributed to minimizing the scope of communicable disease transmission in Canada.
What remains a major concern in this country, and worldwide, is the transmission of diseases
that are deemed to be less severe. Notably, many respiratory and gastrointestinal tract infections are
somewhat neglected due to a misinformed low level of hazard witnessed amongst the public. Globally,
seasonal influenza virus affects an innumerable population and causes severe illness in three to five
million. Amongst these, 250,000 to 500,000 result in death (WHO, 2010). In Canada, depending on the
active strain and the severity of the season, influenza virus kills between 2,000 and 8,000 annually
(PHAC, 2010).
Similarly, gastrointestinal tract infections transmitted through the fecal-oral route remain a
major public health concern in Canada. In 2009, the Public Health Agency of Canada’s National Enteric
Surveillance Program recorded 14,262 cases of laboratory confirmed enteric disease in Canada. Due to
notorious underreporting of these notifiable diseases, PHAC estimates the true number of individuals
affected annually to be greater than one million (PHAC, 2011). While the majority of these enteric
infections are likely food or waterborne in nature, it is assumed that a significant percentage can be
attributed to environmental contamination and person-to-person spread. Antivirals and antibiotic drug
therapies have been developed to combat respiratory and gastrointestinal tract infections, but as a
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simple rule of thumb for communicable disease, it is easier and far more cost effective for health care
systems to prevent infection rather than treat and care for individuals post-infection.
With this emphasis on preventive measures, vaccination programs have flourished and have
since had an observable impact on suppressing the rate of transmission. However, in medical clinic
waiting rooms, those very individuals waiting for vaccines, as well as the patients sitting in close
proximity, may be subject to an increased risk of infection from their immediate environment.
Overlooking the potential of spreading disease in these settings is simple because these facilities are
specifically designed to treat illnesses; in reality, waiting rooms are a prime location for disease
transmission. Research and common sense tells us that the concentration of pathogens harboured by
infected individuals in a confined space such as medical clinic waiting rooms is certainly a cause for
concern (Hogg et al., 2006 and Siegel et al., 2007). The level of risk is exacerbated by those that are
immunocompromised by means of age (infants, children, and elderly), pregnancy, or underlying medical
conditions.
In response to these growing concerns and to mitigate the risk, leading public health agencies
and organizations have developed infection prevention and control guidelines to be implemented in
these community based settings. The battle to fight infection not only relies on health care providers to
practice high standards of personal and facility hygiene, but should also include a comprehensive plan
for clinic design and the enforcement of infection prevention and control policies or operating
procedures that are targeted at suppressing disease (Campos-Outcalt, 2004). The British Columbia
Centre for Disease Control (BCCDC) and the College of Physicians and Surgeons of British Columbia
(CPSBC) agree; the introduction of their specialized infection control document for medical clinics states:
“Education of all health care providers regarding the epidemiology and specific precautions pertaining to
the prevention and control of infectious diseases should be carried out to ensure personnel are
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educated appropriately and understand their responsibilities. Policies for infection control and
prevention should be written, readily available, regularly updated, and enforced.”
Literature Review
When reviewing research studies that have focussed on disease transmission in community
based health care settings, information on the subject of influenza virus is noticeably limited. While
there is a plethora of information available on influenza in general, specifically studying virus
transmission and survival in the clinic environmental has proven to be quite difficult for a variety of
reasons. Firstly, the complex nature of the virus itself leads to great microbiological constraints (Hirst,
1947). Multiple strains that vary in incidence rate depending on the season and the year, genetic
variation, and constant DNA mutation make isolating the virus from individuals difficult. Further, the
high incidence of seasonal influenza makes tracing individual cases and confirmation through laboratory
diagnostics extremely resource intensive and impractical (CDC, 2010). The lack of definitive evidence for
influenza virus transmission is particularly alarming because influenza may be the agent that is the single
greatest concern in these establishments. The sheer number of infected that enter clinics on a daily
basis, and the looming potential of an influenza pandemic should put the management of influenza at
the head of infection prevention and control programs.
Despite the difficulties in tracing such infections, in a review of 1,000 health care associated
outbreaks, 83% were acquired in hospital settings. The remaining 17% were attributed to community
based settings, 80% of which are office based practices. Furthermore, 17 health care associated
influenza outbreaks were successfully identified between the years of 1959 and 1994 and in 5 of these
cases, health care workers were implicated in transmission of the virus (Lautenbach et al., 2010). These
documented events substantiate the assumption that patients, visitors, and staff all play a key role virus
spread. While influenza virus may be the agent of primary concern in these settings, other etiologic
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agents have been implicated. To fully understand the public health impact posed by all these
communicable diseases, pathogen survival, modes of transmission, and characteristics of the
environment itself should be examined.
Pathogen survival in the medical clinic environment
Studies have provided evidence that laboratory grown influenza A and B can survive for 24 to 48
hours on hard, non-porous surfaces such as stainless steel and plastic, and as long as 8 to 12 hours on
cloth, paper, and tissues. Additionally, measurable quantities of virus can survive for up to 5 minutes on
hands after transfer from environmental surfaces (Bean et al., 1982). These findings link the shedding of
virus particles by the infected onto environmental surfaces and subsequent infection of susceptibles
from touching said surface shortly thereafter.
Later studies have shown other strains of influenza to be equally robust. Parainfluenza virus can
survive for up to 10 hours on non-absorptive surfaces such as stainless steel, laminated plastic, and skin
and up to 4 hours on absorptive surfaces such as clothing and facial tissues. Furthermore, it has been
shown that drying of the viral inoculums does not immediately inhibit virus survival (Brady et al., 1990).
The ability of influenza virus to survive in a dried state for prolonged periods of time outside of a host
was yet another significant advancement in understanding the transmission of this disease.
A later study conducted in 1995 focussed on the survival of rotavirus on environmental surfaces.
It was determined that contaminated surfaces were indeed a plausible source of pathogenic microbes.
Surfaces involving human activity, also known as “high-touch” areas, were most at risk for harbouring
the virus. Toilet handles, televisions, toys, and vital signs charts all yielded positive rotavirus test results
(Akhter et al., 1995). Studies such as this further indicate the need to consider fomites as a possible
vehicle for transmission. In these circumstances, a simple program of environmental disinfection and
frequent handwashing can greatly reduce the likelihood of cross-infection, if not completely eliminate it.
x
In addition to viruses, researchers have meticulously studied the survival of bacteria, fungi, and
yeasts on inanimate objects. In 2006, Kramer et al. proved the survival of a broad spectrum of
pathogens that have been linked to nosocomial infections. The persistence of bacteria on inanimate
objects was outlined by the survival of both gram positive and gram negative species including
Enterococcus, Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Shigella spp., as well as
fungi and yeasts including Candida albicans and Torulopsis glabrata. This entire selection of etiologic
agents was capable of surviving multiple months on inanimate objects, again suggesting the importance
of routine disinfection of the immediate environment in health care settings (Kramer et al., 2006). The
study also demonstrates that in addition to respiratory infection, there exists threats of bacterial
(Pseudomonas aeruginosa) and fungal (Candida albicans) skin infection and gastrointestinal tract
infection through fecal-oral route ingestion of enterics (Enterococcus, Escherichia coli, Shigella).
Demonstrating the robust nature of these pathogens validates the hypothesis that these
environments do pose a significant risk to the public. Infections by direct contact through inhalation of
droplets or through indirect contact with environmental surfaces, specifically by subsequent self
inoculation through the conjunctiva, other mucous membranes, or orally by ingestion, are the greatest
hazards to public health.
Disease transmission in the medical clinic environment
The aforementioned studies confirmed that influenza virus, amongst other viruses, bacteria, and
fungi, can survive for prolonged periods of time in the office setting. Unfortunately, as stated earlier,
the sheer prevalence of the influenza virus makes tracing the origin of individual infections back to the
medical clinic waiting room nearly impossible. As a result, researchers have predominantly investigated
the transmission of less common, and hence, more easily traceable respiratory infections. Amongst the
studies that have examined waiting rooms as a potential setting for communicable disease transmission,
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those that have retrospectively analyzed previous outbreaks to trace them back to the source have been
particularly constructive.
One of the first of such studies was carried out in 1985 by Remington et al. Here, an unusual
outbreak of measles which occurred in 1982 in Muskegon, Michigan was investigated. The results
showed that 3 children, who entered the waiting room roughly one hour after the index case left,
developed measles. Severe coughing, increased warm air recirculation, and low relative humidity, were
all cited as contributing factors to the transmission of the agent. In their summary, Remington et al.
suggested that airborne transmission of infectious agents within the office setting may occur more often
than previously expected. As a result, they recommended the re-evaluation of measles control
strategies. The following were deemed effective measures in decreasing the risk of measles virus
transmission in the office setting: adequate immunization of all patients and staff, respiratory isolation
and airborne precautions, initial screening and prompt care of suspected cases, and an adequate fresh
air or treated air supply (Remington et al., 1985).
A strikingly similar outbreak occurred one year prior in DeKalb County, Georgia. Again, the
outbreak was successfully traced back to the medical clinic waiting room. In this scenario, an infectious
child with an extremely productive cough led to 7 secondary cases of measles infection due to exposure
in the physician’s office (Bloch et al, 1985). In both of these scenarios, the high level of communicability
of the measles paramyxovirus should be noted. Droplet nuclei are easily generated and can survive for
at least one hour when spread by airborne transmission (Bloch et al., 1985). However, the lack of
proper isolation, failure to triage highly infectious patients, poor ventilation design, and low rates of
vaccination were all contributing factors that may have mitigated risk and lessened the scope of this
outbreak.
A more recent study looked into the possibility of Mycobacterium tuberculosis transmission
within the outpatient setting. This research was carried out by Moore et al. in 1998 in a paediatric
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health care setting. These situations are of special interest in public health pursuits because children
represent a high risk population that is particularly susceptible to infection. In total, 1,416 patients were
defined as exposed to the M. tuberculosis bacteria in the clinic setting. Of those that were screened, 14
showed a positive tuberculin skin test result. As only seven of the cases were US born, it was
hypothesized that the remaining 7 cases may have been exposed to the agent outside of the United
States where prevalence of tuberculosis is greater. While no active cases of tuberculosis were identified
in the study, the positive skin test results do provide evidence of potential transmission of latent M.
tuberculosis in these settings (Moore et al., 1998). These findings again demonstrate the importance of
all infection control strategies in community based health care offices, but particularly those strategies
designed to minimize the risk involved with highly communicable respiratory infections.
The high-risk nature of the medical clinic environment
As the previous studies have suggested, pathogen survival on inanimate objects can be proven
within the confines of the laboratory. However, few of the aforementioned studies directly sampled the
clinic environment. For the purposes of practicability, the results of such studies would provide far more
insight into the potential transmission of disease. In these studies, all variables and confounding factors
that cannot otherwise be simulated in the laboratory are accounted. In 1980, Hall et al. demonstrated
the possibility of respiratory syncytial virus (RSV) transmission via fomites. Similarly in 2002, Merriman
et al. discovered that toys were a potential source of cross-infection in general practitioner waiting
rooms. These two studies are linked because they each tested for contamination of environmental
surfaces in the actual health care setting.
RSV was found to be capable of surviving on countertops for up to 6 hours, 1.5 hours on rubber
gloves, 30 to 45 minutes on cloth gowns or paper tissues, and up to 20 minutes on skin (Hall et al.,
1980). Self inoculation by contacting surfaces that have been contaminated with infant secretions was
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thus found to be a potential mode of RSV infection. The complications of RSV have also been
documented in immunocompromised adults. Amongst this susceptible population, a cluster of
infections in 1987 and 1988 was brought into the spotlight following the death of 3 individuals who were
epidemiologically linked by geography. Although two different strains of RSV were characterized, it is
believed that the majority of the infections in the cluster, including the 3 fatal cases, were contracted
within an outpatient setting. Here, the 3 deaths underscore the potential consequences and the
apparent prevalence of infections acquired in outpatient settings (Englund et al., 1991).
The level and extent of fomite contamination has also been explored within community based
health care facilities. In many medical clinics, toys are commonly provided to children in the waiting
areas. Such toys were tested by Merriman et al. in 2002 and found to be significantly contaminated
with fecal coliforms. Hard toys showed low level contamination in 13.5% of the items tested. The
astounding results were those that were obtained when testing soft toys. These were far more likely to
become contaminated as 20% of the items yielded a moderate to heavy level of coliform contamination.
Additionally, 90% showed a moderate to heavy level of bacterial contamination in general. These
findings confirm that soft toys are far more hazardous than hard toys for a variety of reasons including
difficulty of cleaning/disinfection and potential ease of recontamination. Accordingly, Merriman et al.
stated that soft toys pose an unnecessary infectious risk to children and recommended that they be
deemed unsuitable for use in medical clinic waiting rooms (Merriman et al., 2002).
The results of the studies carried out by Merriman et al. were supported in a similar study two
years later. Once again, children’s toys in paediatric health care settings were analyzed as a potential
bacterial source. The results paralleled the findings of Merriman et al. as every sample out of a total of
70 toys tested positive for at least one pathogenic organism. More specifically, 78% of the toys were
positive for coagulase negative Staphylococcus, 37% for Bacillus spp., 18% for Staphylococcus aureus,
11% for alpha-haemolytic Streptococcus, 9% for Pseudomonas spp., 3% for Stenotrophomonas
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maltophilia, and 11% for other potentially harmful gram negative organisms. The researchers also
demonstrated the effectiveness of simple cleaning to significantly decrease bacterial growth rates (Avila-
Aguero et al., 2004). A third related study looked into the bacterial contamination of children’s toys in
neonatal intensive care units. In addition to the pathogenic organisms successfully isolated in the Avila-
Aguero study, these researchers were able to isolate Micrococcus spp., methicillin-resistant
Staphylococcus aureus (MRSA), diptheroids, group B Streptococcus, group D Streptococcus, and two
coliforms (Davies et al., 2000). Fungus was deemed to be of minimal risk, but the high degree of
bacterial colonization found in all three studies re-enforces the potential threat posed by the re-use of
communal toys.
Research lays the foundation for infection control program planning
The previously cited studies constitute only a small fraction of the extensive research that has
been conducted on health care associated infections. The large bulk of these studies have focussed on
the potential for agent transmission. More specifically, the likelihood of acquiring infections in clinic
settings and the survival of agents in these settings has been systematically examined. These findings
have been paramount in guiding the planning and implementation of infection control strategies set out
by various public health organizations including: the Public Health Agency of Canada (PHAC), the
Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), BCCDC, the
Canadian Paediatric Society (CPS), the Canadian Standards Association (CSA), the Canadian Task Force
on Preventive Health Care (CTFPHC), CPSBC, the American Academy of Pediatrics (AAP), and the
American Occupational Safety and Health Administration (OSHA), amongst many others. In a
collaborative effort to minimize the risk of communicable disease transmission in community based
health care settings, these parties have all created and offered long lists of infection prevention and
control guidelines specifically designed for these facilities.
xv
However, the usefulness of these efforts, both the initial studies and the resulting advancement
in the development of guidelines, will not be fully realized unless the recommendations are put into
practice. It should be noted that the use of these guidelines is not a regulated standard for these
settings, nor is it a consistent and standardized list between public health organizations. The guidelines
are merely recommendations set by the local, national (Canada and the United States), and
international leaders in public health. To date, little work has been done to monitor and assess the level
of buy-in amongst medical clinics regarding these infection control precautions.
Purpose of the Study
Communicable disease research has lead to improvements in infection control program
planning. The objective of this study was to bridge the gap that currently exists between program
planning and program effectiveness, a process that requires monitoring program execution. This was
accomplished by gauging the level of infection prevention and control precautions taken at numerous
medical clinics in the city of Vancouver, and assessing if these clinics achieve a level that is deemed
satisfactory for minimizing the risk of communicable disease transmission. Clinics were separated into
two categories: those located in regions of ‘high’ socioeconomic status (Westside Vancouver) and those
located in regions of ‘low-medium’ socioeconomic status (remainder of Vancouver). The clinics were
graded through a set of 15 criteria and assessed by both visual observation and surveying of health care
staff. The results of this investigation will work to help achieve the ultimate public health goal of
eliminating any infection control deficiencies that contribute to preventable illnesses contracted within
medical clinic waiting rooms.
xvi
Experimental Procedure
Materials and clinic selection
Data collection was done by visual observation and in-person surveying. For this reason, the
materials required during initial data collection were nothing more than a means of transportation (car)
and a recording device (laptop computer). Statistical analysis of the collected data required more
complex computer software, including Microsoft Excel 2007 and NCSS 2007. Data collection was carried
out during the winter of 2010-11 between the months of December and March. The time of year was
ideal for such a study because these months correspond to the peak of influenza season in North
America. Thus, the infection control measures assessed were of utmost importance during this time
frame.
The first step of assessing the infection control measures in the Vancouver area was to
specifically define regions of different socioeconomic status for comparison. To categorize Vancouver
neighbourhoods into regions of ‘low-medium’ versus ‘high’ status, socioeconomic profiles compiled by
BC Stats using the results from the Canada 2005 Census were consulted (BC Stats, 2009). The two areas
thoroughly analyzed were the Vancouver Local Health Area (LHA) with the highest average annual family
income ($143,288) – Westside Vancouver, and the remaining Vancouver LHAs with a measurably lower
average annual family income ($72,216) (Figure 1 and Table 1).
xvii
Figure 1. Map of Local Health Areas (LHAs) in Vancouver, as defined by the BC Ministry of Health (BC Stats, 2010). Regions of ‘high’ socioeconomic status are depicted in green (Westside Vancouver) and regions of ‘low-medium’ socioeconomic status are illustrated in yellow (the remainder of Vancouver).
Table 1. Income measures in Vancouver gathered from the socioeconomic profiles of Local Health Areas (LHAs) as described in Statistics Canada 2005 Census (BC Stats, 2009). Local Income Measures in Vancouver Local Health Area (LHA) Average Family Income ($) Vancouver - City Centre (161) 88,485 Vancouver - Downtown Eastside (162) 59,424 Vancouver - Northeast (163) 67,271 Vancouver – Westside (164) 143,288 Vancouver - Midtown (165) 73,637 Vancouver – South (166) 72,264 Vancouver - Average (Westside Excluded) 72,216
xviii
Socioeconomic status was chosen as the variable for comparison because previous studies had
revealed a graded association between socioeconomic status and health outcomes (Adler and Ostrove,
1999). Additionally, the availability of BC Stats Local Health Area maps provided areas with defined
geographic boundaries and validated income measures, thus removing any ambiguity that may have
been associated with alternative variables.
After the regions were defined, a statistically relevant sample size of 30 clinics in each region
was targeted. Selection of clinics in each respective region was done by random draw of all the clinics
that lie within the geographical boundaries set out by the BC Ministry of Health (Figure 1). Clinics were
identified using the ‘Find a Physician’s Contact Information’ tool on the official website of the CPSBC
(CPSBC, 2011). All eligible clinics that fell within each target region were assigned numbers starting at 1
in each territory. The numbers representing clinics in each region were then randomized using
Microsoft Excel 2007 and clinics were visited until a statistically relevant sample size of participating
clinics was reached. At the conclusion of data collection, 35 clinics were chosen to participate in
Vancouver, but only 25 clinics qualified for participation in Westside Vancouver (Figure 1).
Development of grading tool
To gauge the level of infection control that was practiced within each individual clinic, a survey
consisting of 15 criteria was created outlining basic and up-to-date guidelines that have been set by
leading public health professionals. Using the information gathered from research, guidelines have
been developed by various parties in an effort to minimize the risk of communicable disease
transmission within the medical clinic setting. Such guidelines and recommendations have been
outlined in medical journals, by international public health organizations (WHO), national public health
agencies (PHAC, US CDC), and by provincial bodies (BCCDC, CPSBC). None of these guidelines are
regulated by law and they do not represent a widely accepted standard for infection control. However,
xix
many recommendations are mentioned in multiple documents, and it was a selection of these that were
used to gauge the level of infection control in the medical clinics of each Vancouver region. Because the
document was readily accessible to the medical clinics in the Vancouver region, assessed infection
control criteria was predominantly selected from the BCCDC and CPSBC’s “Guidelines for Infection
Prevention and Control in the Physician’s Office” (BCCDC, 2004).
Graded control measures were broken down into those that can be assessed by simple visual
observation and those that required surveying of health care providers.
Infection control guidelines assessed by visual observation:
1. availability of alcohol based hand antiseptics
2. accessibility to handwash basin that is fully stocked for proper hand hygiene
3. discontinuation of the use of faucet aerators
4. availability of single-use tissues and disposal in no-touch/foot-use receptacles
5. posting of signage or visual alerts for proper handwashing techniques
6. posting of signage or visual alerts for proper coughing and sneezing etiquette
7. triaging procedures for clients exhibiting symptoms of communicable disease (e.g. cough, fever,
rash, etc.) including signage or visual alerts to report symptoms immediately
8. floors constructed of hardwood, linoleum, or other hard surface that is easily cleaned,
disinfected, and impervious to moisture
Infection control guidelines assessed by surveying health care staff:
1. availability of facial protection/masks for patients that are symptomatic with productive cough
2. daily cleaning and disinfection schedule for environmental surfaces
3. screening of patients for cough, fever, or other symptoms indicative of infectiousness
4. enforcement of recommended distance barriers (e.g. greater than one metre from patients with
flu-like symptoms)
5. availability of staff training or formal education in infection prevention and control
6. written procedures for staff exclusion or work restriction policies for health care providers
exhibiting signs and symptoms of contagious illness
7. recommendations that health care providers receive standard immunizations including seasonal
influenza vaccine
xx
Inclusion and exclusion criteria
This study was limited to the city of Vancouver itself. All other cities in the BC Lower Mainland
were excluded from the study including North Vancouver, Richmond, Coquitlam, New Westminster,
Burnaby, and Surrey. Any medical clinic that fell within the geographic boundaries outlined in Figure 1
was eligible for participation. The exceptions were paediatric clinics. The reasoning behind this
exclusion is the susceptibility of infants and children to infection. There was a possibility that paediatric
clinics may tend to exercise more precaution than would normally be seen in a standard medical clinic
and thus give a positive bias to the data indicating that infection control procedures in these settings
was at a superficially high level. Moreover, for the sake of consistency and an accurate final
representation of one type of facility, all other community based health care settings such as dental,
chiropractic, and acupuncturist practices were excluded. Finally, data was only collected from clinics
that provided written consent to participate in the study.
Pilot study
Prior to the collection of data, an initial pilot study was conducted on a small sample of medical
clinics in the city of Burnaby which lies outside of the target regions. This step identified potential
problems regarding feasibility and also functioned to test the relevance of the selected infection control
measures. Additionally, the pilot study served to determine potential problems with vagueness and
understanding of the criteria that required an in-person survey of health care staff. After all the
problems identified during the pilot study were corrected, data collection was cleared to commence.
As a direct result of the pilot study, a number of grading criteria were either eliminated or
modified. Firstly, it was determined that the majority of health care staff was unaware of the type of air
circulation system used in their respective clinics. Therefore, rather than risk jeopardizing validity
through the acceptance of ‘guessed’ answers, the infection control recommendation of using treated,
xxi
HEPA filtered air in negative pressure rooms was not assessed. Secondly, it was observed that a large
majority of clinics have discontinued the use of communal children’s toys. As a result, the infection
control guidelines of discontinuing the use of soft toys and adhering to a daily cleaning and disinfection
schedule for hard toys were also excluded from grading. Other criteria such as potential overcrowding
or escorting of immunocompromised to private rooms were eliminated due to issues with ambiguity
and confidentiality. Finally, due to the ongoing ethical debate regarding compulsory immunizations,
only recommendations for standard staff vaccinations was assessed.
Results and Analysis
Because each criterion that was assessed resulted in a yes or no response, the raw data
collected was a dichotomous and nominal scale of measurement. The number and percentage of clinics
practicing each individual infection control measure was totalled and then calculated. This was done by
summing the number of clinics that practiced each guideline, resulting in a total score out of 25 in
Westside Vancouver and 35 in the remainder of Vancouver. This number was converted into a
percentage and the value was indicative of the control measures that are most commonly implemented
and which control measures seem to be lacking in the Vancouver region as a whole (Appendix A and B).
Individual clinics were further graded by aggregately scoring all infection control measures and
awarding a total score out of 15. Scoring in this manner yielded a discrete and numerical data set that
could be interpreted by both descriptive and inferential statistics. The 35 scores obtained from the
clinics located in areas of ‘low-medium’ socioeconomic status (Vancouver) were compared to the 25
scores obtained from clinics located in areas of ‘high’ socioeconomic status (Westside Vancouver).
xxii
Descriptive statistics
Using the Microsoft Excel 2007 Software Program, regions were compared by descriptive
statistics to calculate the measures of central tendency. The best statistical measure to describe this
data was mean score, as opposed to median score, because the data yielded a roughly symmetrical
distribution with a limited number of outliers. Range of scores was also measured by descriptive
statistics (Table 2). This measure of dispersion was useful to spot the disparity that exists between the
clinics that practice excellent infection prevention and control versus those that seemed to be deficient
in their practices. Finally, percentages were utilized to gauge which infection control measures are most
commonly practiced and which, if any, appeared to be neglected in the regions studied (Appendix A and
B).
Inferential statistics
The data was tested for both normality and variance, and then interpreted with inferential
statistics using the NCSS Statistical Analysis and Graphics Software Program. This computing package
allowed statistical comparison of the clinics located in regions of different socioeconomic status on a
level deeper than that described by Microsoft Excel. The aggregate scores of each local health area
were specifically of interest in the study. A simple statistical tool applied for testing differences between
two means is the standard T-test (Appendix D and E). A couple major advantages of using the T-test in
this study are that T-tests often provide statistically relevant results even when sample sizes are
relatively small and they also provide realistic results because they are done under the assumption that
standard deviations are unknown (Adeyemi, 2009).
xxiii
Research results and analysis
By computing descriptive statistics with Microsoft Excel, the clinics located in regions of ‘low-
medium’ socioeconomic status (Vancouver) scored an average of 10.86 out of a possible 15 infection
control criteria (72.4%). The poorest performing clinic scored 7 (46.7%), while the highest rated clinic
received a grade of 14 (93.3%). By comparison, clinics located in regions of ‘high’ socioeconomic status
(Westside Vancouver) scored an average of 10.92 out of 15 (72.8%). The poorest performing clinic in
this region scored 6 (40.0%), while the highest rated clinic received a perfect score of 15 (100.0%) (Table
2).
Computing inferential statistics using NCSS software yielded a standard deviation and standard
error of 9.72 and 1.64 respectively for clinics in Vancouver. The lower and upper limits for mean
percentage using a 95% confidence interval were 69.04 and 75.72 (mean = 72.4). By comparison, clinics
in Westside Vancouver showed a standard deviation and standard error of 14.90 and 2.98. Lower and
upper values for 95% confidence intervals were 66.65 and 78.95 (mean = 72.8) (Table 2). The results of
the two-tailed, two sample Aspin-Welch Unequal-Variance T-test compute a p-value of 0.902624 with a
statistical power of 0.051654. Assuming regions of ‘high’ socioeconomic status would show higher
standards than regions of ‘low-medium’ socioeconomic status, a one-tailed t-test yields a p-value of
0.451312 with a statistical power of 0.063773 (Table 2 and Appendix D).
xxiv
Table 2. Summary of descriptive and inferential statistics calculated using Microsoft Excel 2007 and NCSS 2007.
High <> Low-Medium P-value = 0.902624 Power = 0.051654
Do not reject H0
P-value, Power
High > Low-Medium P-value = 0.451312 Power = 0.063773
Do not reject H0
In addition to aggregately grading clinics in the two regions, each individual infection control
criteria was also analyzed to determine which measures are most commonly in practice and which
measures are still in need of implementation. Availability of alcohol-based hand antiseptics (95.0%),
handwash basins properly stocked for hand hygiene (88.3%), discontinuing the use of faucet aerators
(83.3%), availability of tissues with appropriate refuse containers (96.7%), availability of facial
protection/respirator masks (100.0%), floors constructed of acceptable material (83.3%), staff
exclusion/restriction policies (100.0%), and recommended staff vaccinations (100.0%) all scored highly.
Cleaning and disinfection schedules for environmental surfaces (68.3%), posted signage for
handwashing (65.0%), and enforcement of recommended distance barriers (53.3%) received moderate
grades. The remaining guidelines scored poorly, including posted signage for respiratory hygiene
(coughing/sneezing etiquette) (41.2%), satisfactory triaging procedures (30.0%), screening patients for
communicable illness (35.0%), and staff policies on training and education (48.3%) (Table 3 and Figure
2).
xxv
Table 3. Summary of combined results for individual infection control criteria.
TOTAL SCORES Low-medium (/35)
High (/25)
Total (/60)
Percent (%)
Alcohol based hand antiseptics 33 24 57 95.0 Handwash basin stocked for hand hygiene 30 23 53 88.3 Discontinuation of faucet aerators 29 21 50 83.3 Tissues with no-touch/foot-use receptacles 34 24 58 96.7 Availability of masks for patients with productive cough 35 25 60 100.0 Cleaning and disinfection schedule for environmental surfaces 24 17 41 68.3 Floors constructed of hard, easily cleanable, non-porous material 31 19 50 83.3 Signage or visual alerts for proper hand hygiene 23 16 39 65.0 Signage or visual alerts for proper coughing/sneezing etiquette 15 10 25 41.7 Appropriate triaging precautions and visual alerts 10 8 18 30.0 Patient screening for communicable illnesses 11 10 21 35.0 Enforcement of recommended distance barriers 19 13 32 53.3 Availability of staff training in infection prevention and control 16 13 29 48.3 Written procedures or exclusion policies for unwell staff 35 25 60 100.0 Recommendations for standard set of staff immunizations 35 25 60 100.0 Figure 2. Graphical representation of combined results displayed as percentage (%) of clinics practicing individual infection control criteria.
xxvi
Interpretation of data
To analyze the inferential statistics provided by NCSS, the normality and variance of the data
was first considered (NCSS, 2007). According to the tests of assumption, we cannot reject normality, but
we can reject equal variances (Appendix D). Because it can be assumed that the variables
(socioeconomic status) are normally distributed, but that variances are unequal, the parametric results
acquired using the Aspin-Welch Unequal-Variance T-test are more relevant than those obtained through
the Equal Variance or the nonparametric Mann-Whitney U, Wilcoxon Rank Sum, or Kolmogorov-Smirnov
Tests (Appendix D). For determining statistical differences between Westside Vancouver and the
remainder of Vancouver, the null (Ho) and alternative (Ha) hypotheses were defined as follows:
H0 : there is no difference between the infection control procedures demonstrated at medical clinics in regions of ‘low-medium’ (Vancouver) versus ‘high’ socioeconomic status (Westside Vancouver). Ha : there is a difference between the infection control procedures demonstrated at medical clinics in regions of ‘low-medium’ (Vancouver) versus ‘high’ socioeconomic status (Westside Vancouver).
When testing if there is a difference in the infection control measures implemented at clinics
located in regions of ‘low-medium’ socioeconomic status versus those located in regions of ‘high’
socioeconomic status, we were unable to reject the null hypothesis, H0, because the p-value was
significantly greater than 0.05 (p=0.902624). This value was obtained using the results of the two-tailed
T-test. However, because one would not expect regions of ‘low-medium’ socioeconomic status to ever
demonstrate higher standards of infection control compared to clinics located in the affluent regions of
‘high’ socioeconomic status, the result of the one-tailed t-test (high status > low-medium status) may
also be applicable. However, using this test yields the same conclusions (p=0.451312) and we again
cannot reject the null hypothesis, H0. In conclusion, we can confidently state that there is no statistically
significant difference in the infection control measures practiced at clinics located in each of the two
socioeconomic regions (Figure 1). Clinics located in Vancouver do not exhibit a lower standard of
infection prevention and control than clinics located in Westside Vancouver. Overall however, with
xxvii
scores of 72.8% (Westside Vancouver) and 72.4% (Vancouver), there seems to be a need for greater
emphasis on infection prevention and control in both regions.
Once these determinations were made via inferential statistics, the potential for conclusion
errors was examined. Because the null hypothesis (H0) was not rejected, alpha (α) or type I errors were
not a potential issue. However, beta (β) or type II errors may occur when there is a difference between
variables despite the test accepting the null hypothesis. The results of this study may be susceptible to
such conclusion errors and a low statistical power (0.051654) suggests that this may be the case. To
reduce the risk of beta errors and subsequently raise the power of the study, it would have been
necessary to increase the sample size of clinics visited in each socioeconomic region.
Discussion In spite of past evidence that health outcomes are directly associated with socioeconomic
status, there was no difference in infection control scores between clinics located in low-medium versus
high socioeconomic regions in Vancouver, British Columbia. However, the statistical power of 0.051654
obtained in the two tailed t-test indicates some probability that the null hypothesis was incorrectly
rejected. In general, a power greater than 80% is desirable to state results with confidence (Heacock
and Crozier, 2010). The low statistical power of 0.063773 obtained in the one tailed t-test indicates that
the rejection of the null hypothesis here is similarly susceptible to beta (type II) errors due to relatively
small sample size.
The lack of discrepancy between socioeconomic regions may in part be due to the fact that the
chosen criteria were largely simple and inexpensive to implement. Thus, a lack of resources and funding
should not be a deciding factor in their compliance. However, the highest standards for infection
control do come with significant costs. For example, the BCCDC recommends that all medical clinics
upgrade to ventilation systems that circulate fresh, treated (HEPA-filtered) air in negative pressure
xxviii
rooms, as opposed to outdated systems that may re-circulate untreated air (BCCDC, 2004). However,
with a significant number of deficiencies noted, a greater emphasis should be placed on getting up to
speed on the easy to implement measures that are currently being underutilized (Table 3 and Figure 2).
After clinics have shown to be capable of implementing these measures to a satisfactory level, the focus
can then be shifted to the more complex guidelines provided by the BCCDC and other public health
organizations.
The simplicity of the grading criteria is worthy of noting once again. Many of the measures
require minimal effort to implement and maintain. For example, the percentage of clinics that failed to
post adequate signage or visual alerts was alarming. Over 30% of clinics did not post a sign outlining
proper handwashing technique (65.0%). Inadequate handwashing and poor personal hygiene remains
the leading cause of person-to-person disease transmission through direct and indirect contact. There is
evidence that contaminated hands and environmental surfaces/fomites play a key role in disease
transmission in these settings. Similarly, over 50% of clinics failed to post signage on recommended
respiratory hygiene (coughing and sneezing etiquette) (41.7%). Here, failure to use the recommended
technique can lead to an unnecessary risk of respiratory infection through large droplet spread and the
production of potentially pathogenic droplet nuclei (i.e. airborne transmission). Finally, over 70% of
clinics failed to post signage or visual alerts stating the importance of immediate reporting of signs and
symptoms. This is necessary to follow satisfactory triaging procedures (30.0%) (Table 3 and Figure 2). In
a confined space such as a waiting room, failing to promptly triage highly symptomatic individuals
unnecessarily increases exposure time to infectious agents for the remaining members of the public.
We can conclude from the previously published literature that transmission does indeed occur through
these means and minimizing time of exposure is an important control measure for respiratory
infections. It was disappointing that only a fraction of clinics is demonstrating diligence with what
appear to be straightforward guidelines pertaining to signage and visual alerts.
xxix
Other criteria that scored disappointingly low included a communicable disease screening
process for patients (35.0%) and the enforcement of recommended distance barriers (53.3%) (Table 3
and Figure 2). Both of these guidelines are related as they have been developed to minimize the risk of
exposure to susceptible populations. Simple screening tools should be developed with the intention of
identifying individuals that are suspected of carrying a gastrointestinal or respiratory infection.
Questions for such a tool would include: the presence of a new or worsening cough, shortness of
abdominal cramps, or recent contact with known sick persons (Canadian Committee on Antibiotic
Resistance, 2007). Once identified, precautions should be taken to isolate these individuals from others
in the waiting room. Immediate escort to private examination rooms is ideal, but simply enforcing
recommended distance barriers in the waiting room should decrease risk if implemented appropriately.
This control measure is dependent on and directly related to the assessment of satisfactory triaging
procedures.
Similar to ventilation which was eliminated as a grading tool during the pilot study, three of the
assessed criteria fell under the category of facility design and layout. The accessibility of handwash
basins (88.3%), acceptable construction materials for floors (83.3%), and the discontinuation of faucet
aerators (83.3%) all scored reasonably high. With the exception of signage and visual alerts, factors
affecting hand hygiene received satisfactory results. Acceptable construction materials refer to the ease
of cleaning and disinfection. For these reasons, carpeting is not recommended in such facilities. In
addition to floors, walls, ceilings, furniture, and fixtures should also be constructed of acceptable
materials, but these were not assessed due to potential ambiguity and variance between clinics. The
BCCDC and CPSBC specifically state that floors should be constructed of hardwood or linoleum, and this
simple standard was chosen for grading. Finally, the criteria regarding the discontinuation of faucet
aerators directly relates to studies that have found these fixtures to promote the growth of biofilm
xxx
forming microorganisms. Of particular concern is the harbourage of Pseudomonas aeruginosa, an
opportunistic pathogen naturally found in the water supply.
In contrast to many others, some infection control criteria graded out extremely well.
Recommendations for a standard set of staff vaccinations (100.0%), staff policies for exclusion/work
restriction (100.0%), the availability of facial protection/masks (100.0%) and tissues for symptomatic
patients (96.7%), and the availability of alcohol-based hand antiseptics (95.0%), all scored over 95%
respectively (Table 3 and Figure 2). The successful rate of compliance with these guidelines suggests
that 90% and above is an achievable goal for all of the selected criteria which are comparable in terms of
complexity.
While the scores obtained were admirable, the topic of vaccination policies for health care
providers is worthy of further discussion. Due to the questionable ethics of such policies, this study only
assessed whether clinics recommended a standard set of immunizations to all staff, students, and
volunteers. To many individuals, a compulsory immunization policy deprives them of autonomy.
However, from a public health standpoint, mandatory vaccinations would be greatly beneficial. High
immunization rates contribute to herd immunity and also provide a safeguard for individuals that are
asymptomatic, but still infectious to others. The need for such vaccination programs would be less of a
pressing issue if current rates of staff immunization were sufficiently high. Unfortunately, the BCCDC
reports that immunization rates for influenza have historically been low amongst health care workers.
Between 2004 and 2010, only 34.7% - 46.3% of staff in BC acute care hospitals chose to receive seasonal
influenza vaccinations (BCCDC, 2011). Data for staff employed at community based medical clinics is
unavailable, but similarly low rates are reasonably expected.
Training and formal education, which cumulatively scored just 48.3% (Table 3 and Figure 2), may
have a far greater impact than any other individual criteria that was assessed. All other measures can
reasonably be linked back to the level of training and education of each individual staff member. At
xxxi
minimum, standard infection control precautions should be part of the initial training process and in an
ideal environment, all staff in these settings should be required to obtain some type of formal education
to understand their responsibilities and their role in minimizing the spread of infectious disease. If
clinics fail to offer these training programs, it can rationally be assumed that compliance with all other
infection control precautions would suffer.
As has been discussed, the criteria graded in this study are only a sampling of the infection
prevention and control techniques that have been developed over time. The mean scores observed in
this study do not in any way represent the standard of infection control within the facility as a whole. It
must be understood that the procedures and activities that occur within examination rooms is also of
great interest to the field of infection control. In this subsection of the medical clinic, potentially
invasive procedures using semi-critical and critical medical instruments give way to a high risk
environment akin to personal service establishments. The proper use of low level, intermediate, high
level disinfectants, and sterilizers are imperative to the safe usage of patient care equipment. General
housekeeping, disposal of anatomical waste, and precautions for blood and body fluid exposure are all
considerations in these facilities that were not assessed due to the study’s restriction to the waiting
room areas.
Each medical clinic also varies in both design and practice. For instance, pediatric clinics will
commonly provide communal toys for young patients in waiting rooms. Guidelines such as these that
only apply to a limited selection of clinics were not assessed. For these establishments, it is even more
important that health care staff review the material that is provided by public health agencies to ensure
that they are diligent in their battle against preventable illnesses. The low to moderate grades achieved
for frequency of environmental cleaning and disinfection lead one to believe that toys are similarly
neglected in many practices. In reality, they pose a great public health threat to a high risk population.
xxxii
While the cleaning and disinfection of communal children’s toys was not specifically examined in
this study, it should be noted that the notion that toys pose an unnecessary risk has been a topic of
study and discussion for a number of years. Internationally, many public health organizations have
taken the work of research studies to put into action recommendations such as cleaning and even
discontinuing the use of soft toys (Bachmeier, 2004 and AAP, 2007). In addition to suggesting the ban of
soft toys, some parties have drawn up innovative strategies for sanitizing and disinfection. To minimize
the risk of transmission due to contaminated toys, Kari Bachmeier and the Committee on Infectious
Diseases and Committee on Practice and Ambulatory Medicine from the American Academy of
Pediatrics (AAP) published material outlining safe procedures for the use of toys in paediatric clinic
waiting rooms (Bachmeier, 2004 and AAP, 2007). The most effective measure to decrease the level of
risk with children’s toys was using a dishwasher to sanitize hard toys on a daily schedule. The high
temperature sanitizing rinse of a commercial dishwasher was not only sufficient to kill most pathogenic
microorganisms present on the toys, but the mechanical action of the wash cycle also worked to
eliminate any organic matter that may otherwise work to feed and shield infectious agents from
disinfection (AAP, 2007).
The theory behind this entire study has been expanded to include other areas of the medical
clinic setting that may pose a risk to the public outside of the waiting room. On a community level, the
same theory can be applied to a variety of settings outside of medical clinics entirely. Infection
prevention and control is a vast field and its principles will apply to many community based health care
facilities including dentistry, chiropractic, acupuncture, podiatry, and many others. Currently, infection
prevention and control in all of these settings is solely the responsibility of the operator.
The current state of public health underscores the importance of infection control. The
emergence of antibiotic resistant organisms is an emerging problem that is of particular concern in
health care settings. Additionally, the impending threat of an influenza pandemic puts preventive
xxxiii
measures in the spotlight. As influenza, amongst other infections, is a community issue, it is distressing
to see the inconsistencies displayed between individual clinics. Scores range from as high as perfect
(100.0%) to 6/15 (40%) (Table 3 and Figure 2). In these instances, the lack of meticulousness
demonstrated at one clinic can undermine the high standards demonstrated at another when
potentially exposed individuals re-enter the community and interact in other public areas.
Limitations The two greatest limitations that held back the scope and overall effectiveness of this study
were time and resources. While the sample sizes obtained were sufficient to provide normalized
distribution in the results, a low statistical power suggests that the findings are susceptible to beta
errors. It would have been ideal to assess a greater number of clinics and achieve a more representative
and statistically significant sample. More applicable results would have been obtained if regions were
expanded to include the entire lower mainland or even the entire province of British Columbia.
However, this again leads back to the aforementioned restraints of time and resources. The research
was conducted by a single investigator to eliminate any inter-rater variability, and expanding the
assessment region would have been impractical working with such a limited time frame.
Furthermore, because no regulated standard for infection control exists for these settings, no
widely accepted list of criteria was available to be used as a grading tool. This resulted in a somewhat
improvised assessment that was created predominantly using a resource provided by the licensing and
regulatory body for the profession (BCCDC/CPSBC’s Guidelines for Infection Prevention and Control in
the Physician’s Office). While an effort was made to select the most universally established measures, it
is entirely possible that some clinics follow a different guide, and hence, may not be aware or have
access to, all the recommendations that were graded. The creation of a standardized grading tool that
would fit the needs of this study resulted in the elimination or modification of some vital infection
xxxiv
control recommendations. For this reason, the results may not be indicative of these facilities’
compliance with infection prevention and control programs as a whole.
Finally, validity may be called into question for criteria that were assessed by surveying health
care staff. To some extent, the use of simple, binary ‘yes/no’ answers resulted in leading questions. For
example, when surveying staff about the availability of facial protection/masks, cleaning and
disinfection schedules, screening, enforcement of recommended distance barriers, staff exclusion/work
restriction policies, recommended staff vaccinations, and staff education, the desirable answer and
appropriate infection control best practice is obvious. Again, due to time constraints, issues with
confidentiality, and consent to access, no verification procedures in the form of written documentation
or follow up visits were utilized in the study. Therefore, depending on the honesty of the answers
provided, the grades obtained for the criteria that relied solely on staff responses over visual
observation may show evidence of a positive bias resulting in artificially high scores.
Conclusions and Final Recommendations
While it may never be feasible from a public health standpoint, all medical clinics should be
striving to achieve perfect scores when the implementation of infection control guidelines is actively
graded. The mean scores of 72.4% and 72.8% in Vancouver and Westside Vancouver respectively, show
that clinics located in these regions both have room for significant improvement. The lack of
discrepancy between the scores of each socioeconomic region, and the evidence of high scores achieved
in regions of low-medium socioeconomic status (Vancouver), hints that it is not a lack of resources that
is keeping clinics from achieving higher rates of compliance. This was to be expected, for the criteria
that were assessed were specifically chosen because they are neither costly nor cumbersome to put into
practice.
xxxv
When comparing individual clinics regardless of socioeconomic region, the wide range of scores
observed (40%-100%) indicates that there also needs to be more consistency between clinics. In a
standardized health care system, members of the general public should not be subject to a greater
degree of risk depending on the medical clinic they choose to visit. Because infection control guidelines
are not currently a regulated standard, the onus is on health care providers to ensure that these widely
available resources are consulted. In doing so, clinics would contribute to a marked decrease in
infections that are acquired in community based health care settings. Accordingly, a significant
economic burden would be lifted from health care resources that can subsequently be funnelled into
the enhancement of other health protection programs. When the gap that exists between infection
control program planning and program execution is finally narrowed, the entire health care system
stands to benefit. Preventive practices and public health must not continue to sit on the backburner of
the system.
The findings in this study suggest that medical clinic compliance with recommended infection
control guidelines may continue to live below expectations without the fear of penalty. Such incentive
may successfully persuade substandard clinics to re-evaluate their current practices. Therefore, it can
be proposed that methods of infection prevention and control in these settings become a regulated
process.
Amongst many others, public facilities such as food service establishments, recreational water
facilities, social care facilities, and personal service establishments are inspected and regulated by
provincial, and sometimes federal, environmental public health professionals. Medical clinics and other
community based health care settings should be in consideration to fall under similar standards. In
addition to being subject to inspection by enforcement officers, clinics ought to be subject to a thorough
facility approval process. In this scenario, structural issues such as layout and design, ventilation,
building material selection, accessibility of handwash basins, and posted signage can be addressed
xxxvi
during the approval process prior to operation. Alternatively, the day-to-day activities such as cleaning,
disinfecting, general sanitation, patient screening, and triaging procedures are also monitored for
effectiveness. By combining an approval process with a schedule of routine inspections, the standard of
infection prevention and control can be greatly improved. For the sake of public health and safety, the
feasibility of such a proposal needs to be assessed and scrutinized by upper level management running
provincial and federal public health programs.
Suggestions for Future Studies
Despite the extensive research that has already been carried out on the topic of infection
control in community based health care facilities, there is still much opportunity for learning and for
subsequent improvement in these high risk settings. Future research may focus on getting to the root of
the problem. That is, surveying of practices to determine why infection control measures are not
implemented may be useful to establish if the issue is a matter of a lack of education, resources,
motivation, or a combination of these factors. If the reasons for the deficiencies are identified,
corrective actions can then more easily be applied.
This study was restricted to the waiting room areas of medical clinics. This restriction was
chosen for the sake of accessibility, feasibility, and potential time constraints. We must remember that
high risk activities and invasive procedures are performed within examination rooms. Thus, infection
prevention and control in this component of the facility is equally, if not more likely to impact public
health. Future studies may seek to examine the compliance of infection control guidelines within the
entire medical clinic establishment, or may similarly expand the scope to include all community based
health care settings including, but not limited to, dental, chiropractic, podiatric, and acupuncturist
offices.
xxxvii
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health care. Canada Communicable Disease Report 28S1: 1-276. 39. Public Health Agency of Canada (PHAC). 1999. Routine practices and additional precautions for
preventing the transmission of infection in health care. Canada Communicable Disease Report 25S4: 1-142.
40. Remington, P.L., Hall, W.N., Davis, I.H., Herald, A., and Gunn, R.A. 1985. Airborne transmission of
measles in a physician’s office. JAMA 253(11): 1574-1577.
41. Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and The Healthcare Infection Control Practices Advisory Committee. 2007. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. <http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf>
42. World Health Organization. 2010. Influenza (Seasonal).
Appendices Appendix A. Assessment of individual criteria in regions of low-medium socioeconomic status by descriptive statistics using Microsoft Excel 2007 Software.
LOW-MEDIUM SOCIOECONOMIC STATUS CLINICS # Clinics
(/35) Fraction % Score
alcohol based hand antiseptics 33 0.94 94.3 hand basin stocked for hand hygiene 30 0.86 85.7 discontinued use of faucet aerators 29 0.83 82.9 tissues w/ no touch (or foot) receptacles 34 0.97 97.1 availability of facial protection/masks 35 1.00 100 cleaning/disinfection schedule for environmental surfaces
24 0.69 68.6
floors constructed of acceptable materials 31 0.89 88.6 signage/visual alerts for proper handwashing 23 0.66 65.7 signage/visual alerts for coughing/sneezing etiquette 15 0.43 42.9 satisfactory triaging procedures 10 0.29 28.6 screening patients for communicable illness 11 0.31 31.4 enforcement of recommended distance barriers 19 0.54 54.3 staff training or education in infection control 16 0.46 45.7 staff exclusion/work restriction policies 35 1.00 100 recommended staff vaccinations 35 1.00 100 Appendix B. Assessment of individual criteria in regions of high socioeconomic status by descriptive statistics using Microsoft Excel 2007 Software.
HIGH SOCIOECONOMIC STATUS CLINICS # Clinics
(/25) Fraction % Score
alcohol based hand antiseptics 24 0.96 96.0 hand basin stocked for hand hygiene 23 0.92 92.0 discontinued use of faucet aerators 21 0.84 84.0 tissues w/ no touch (or foot) receptacles 24 0.96 96.0 availability of facial protection/masks 25 1.00 100 cleaning/disinfection schedule for environmental surfaces 17 0.68 68.0 floors constructed of acceptable materials 19 0.76 76.0 signage/visual alerts for proper handwashing 16 0.64 64.0 signage/visual alerts for coughing/sneezing etiquette 10 0.40 40.0 satisfactory triaging procedures 8 0.32 32.0 screening patients for communicable illness 10 0.40 40.0 enforcement of recommended distance barriers 13 0.52 52.0 staff training or education in infection control 13 0.52 52.0 staff exclusion/work restriction policies 25 1.00 100 recommended staff vaccinations 25 1.00 100
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Appendix C. Socioeconomic profiles of Vancouver’s Local Health Areas (LHAs) based on information collected for the income measures of families in the Statistics Canada 2005 Census (BC Stats, 2009).
Appendix D. Results printout of Two Sample T-test run using NCSS 2007. Due to the results of the tests of assumption, the equal variance t-test was used to interpret the data.
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Appendix E. Graphical results printout of Two Sample T-test run using NCSS 2007.
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