Riverview Medical Group Overview

Report to: Board of Health

Meeting Date: June 1, 2016

Report Number: BOH Report – BH.01.JUN0116.R09

Prepared by: Dave George, Emergency Preparedness/Health & Safety Officer Janice Walters, Manager, Control of Infectious Diseases                                                                                   

Rosalyn LaRochelle, Manager, Clinical Services

Lise Trotz-Williams, Epidemiologist

Chuck Ferguson, Manager, Communications

Justin Brown, Manager, Human Resources

Approved by: Robert Thompson, Director, Health Protection

Submitted by: Dr. Nicola Mercer, Medical Officer of Health & CEO

 

Recommendation(s)

(a) That the Board of Health receives this report for information.

EXECUTIVE SUMMARY

On Monday, February 8, 2016, Wellington-Dufferin-Guelph Public Health (WDGPH) staff conducted an unannounced inspection at the offices of the Riverview Medical Group (RMG) in Fergus. This was carried out in response to a public complaint with respect to the cleaning and storage of medical equipment. Inspection findings were reviewed with the Medical Officer of Health (MOH) and the decision was made to remove all reusable medical instruments from the practice and not to permit further reprocessing of instruments at RMG. The public health requirements for the investigation of Infection Prevention and Control (IPAC) lapses in facilities operated by regulated health professionals have recently been enhanced.1,2  As such, staff consulted with the Ministry of Health and Long-Term Care (MOHLTC) and Public Health Ontario (PHO) for direction on dealing with this matter. Additionally, WDGPH is obligated to advise the College of Physicians and Surgeons of Ontario (CPSO) of IPAC lapses in a medical practice and to disclose this IPAC lapse to the public, which was done through the WDGPH website. Based on discussions about risk assessment with PHO and in consultation with RMG, all patients who had two specific medical procedures done at RMG were notified in writing. On March 2, WDGPH activated its Emergency Response Plan and initiated an Incident Management System (IMS) response in accordance with the Public Health Emergency Preparedness Standard and Protocol, given the scope of the event and the large number of patients involved.3 IMS allows for the redeployment of staff from their normal responsibilities to insure the Agency has sufficient staff available to deal with the event. Management of this event involved staff from all program areas as well as the administrative departments of WDGPH.

BACKGROUND

Incident Management System Response Overview

The RMG investigation was managed using the WDGPH IMS, which is part of the WDGPH Emergency Response Plan. On March 2, a planning meeting was held to discuss the unfolding events of the RMG investigation. Between February 5 and March 2, the Control of Infectious Diseases (CID) Program had conducted an investigation regarding infection control concerns raised with the reprocessing of reusable medical equipment at RMG (they were operating under normal conditions and were not in IMS mode during this period). At the March 2 meeting it was decided that the WDGPH Emergency Response Plan would be activated in order to activate the WDGPH IMS. This would increase the Agency capacity to manage the RMG investigation moving forward due to the large number of patients that needed to be contacted and the requirement to redeploy resources within WDGPH programs beyond normal levels, such as nurses, inspectors, communications and administration staff.   

IMS Activation Phase

At the first two IMS business cycle briefings (March 2 and March 7) the situation was assessed, incident objectives were developed, the IMS Control Group was formed, staff received their assignments according to the IMS command structure and their Job Action Checklists outlining their roles and responsibilities, and the IMS organizational chart was created according to staff assignments (see Appendix A). The IMS organizational structure is outlined in this chart and is comprised of the following: Command Section (MOH, Emergency Preparedness Health & Safety Officer, Incident Commander, Safety Officer, Communications Officer, Liaison Officer, and Scribe), Operations Section, Business Continuity Section, Planning and Surveillance Section, Logistics Section and Finance/ Administration Section.

IMS Response Phase

There were 13 IMS business cycle briefings between March 2 and April 13 during the IMS Activation and Response phases. Throughout the Response Phase of IMS staff completed all tasks of their assigned positions, maintained activity logs, completed standard forms and reports to maintain records and accountability. During each business cycle minutes were recorded and the Incident Action Plan (IAP) was updated outlining action items to be completed before the next business cycle.  

IMS Recovery Phase

Recovery from an incident begins as soon as the active Response Phase has ended. The volume and scope of the response work started diminishing in early April, and on April 13 it was decided to exit IMS mode. Even though it was decided to exit IMS, the IMS structure was maintained in the Recovery Phase, as all areas still had recovery activities that take time and resources to complete. A recovery meeting was held on April 26 to determine key actions and tasks that still required attention. A debriefing is planned for early June with the IMS Control Group to capture the findings of the response and to determine what the successes were and what items need improvement for future responses.

Communications

Under the Command Section, the Communications Officer ensures accurate, up-to-date information is provided to the media, the public and staff, and the Liaison Officer maintains links with other agencies involved in the emergency response.

Communications provided a draft letter for RMG to send to patients advising them to be tested if they had the procedures in question during the time period prescribed. On March 11, RMG sent out 1,200 letters to patients and WDGPH sent out a corresponding Physicians Advisory to alert local primary care providers to the situation. This was followed up by a media release sent on March 14 and a blog published by the MOH on March 15. Communications created a full communications plan including tweets, Facebook posts, website information, a fact sheet, Q&As, key messages and media speaking points in preparation for public or media inquiries.

RMG referred all media inquiries to WDGPH. Within seven minutes of the media release being issued, media outlets starting sharing the information on their social networks. CBC Kitchener-Waterloo, CTV Kitchener, CJOY/Magic, Wellington Advertiser and The Grand (Fergus radio) all shared information within the first hour of sending the release. Overall, there were 14 media stories printed or aired on traditional media venues with seven of them including an interview with the MOH. These media stories generated 1.6 million potential readers.

On WDGPH’s website and social media platforms, a Health Alert was viewed over 1,045 times. By monitoring Facebook and twitter accounts of different media outlets it became apparent that there was consistent commentary on why WDGPH officials found the infection control relapse now, and expressions of anger toward WDGPH not warning the public earlier when it was perceived that this lapse had gone on for years. WDGPH responded directly to these comments clarifying the Agency’s role and the complaint-driven inspection process. A blog was published by the MOH, “Inspecting Regulated Health Professionals – Public Health’s Role.”  This is the most read blog of 2016 to date.

Communications coordinated the mailing of negative results to patients and followed up on missing and incorrect addresses. Both courier and registered mail were used to ensure results were sent out as quickly as possible. 

Communications worked with the CID team to create a poster of reprocessing tips to explain the role of health professionals in ensuring there isn’t an infection control lapse in their offices. The poster was sent to all physicians and dentists along with a letter from the MOH clarifying the role of WDGPH and the importance for each office to follow proper infection control practices as prescribed by the CPSO and the Royal College of Dental Surgeons of Ontario.  

Operations

The Operations Section manages all activities required to directly resolve the incident. Operations’ goals for Phase 1 and 2 of the response were consistent with 2016 Strategic Directions:

to provide excellent service to anyone interacting with Public Health during this response; and
to monitor our capacity to effectively respond to a large public health investigation.

Operations – Phase 1 (Warning/Preparedness Phase)

On the afternoon of Friday, February 5, WDGPH received an infection control complaint and conducted an unannounced inspection of a medical practice in Fergus, at RMG, on the next business day, Monday, February 8. The IPAC lapse identified and the subsequent investigation and response was conducted in accordance with the Infectious Diseases Prevention and Control Standard, with consultation from PHO and the MOHLTC and in collaboration with RMG.4

Throughout the preparation phase, Operations provided background information, content and technical knowledge to the Communications’ section so that key messages and fact sheets could be prepared in advance to respond to questions from the clients, the public and the media. All resources prepared for the response received a final review to ensure accurate, thorough and consistent information about the investigation, IPAC best practices and testing recommendations.

Operations developed the call centre resource binders which were placed at each phone and contained copies of all relevant information for staff responding to and documenting calls in the WDGPH electronic medical record, Excelicare. Operations was also responsible for testing the call centre before going live. One of the initial challenges was determining the number of nurses needed to staff the call centre. Operations planned for six operators per shift initially then scaled back during the Impact Phase when the demand was lower than anticipated.

Operations – Phase 2 (Impact Phase)

Operations prepared for a response to two major action items:

1)  RMG’s mail out of notification letters to affected clients on March 11; and

2)  A media release which would be issued by WDGPH on March 14.

In advance of the media release, a Physicians Advisory was prepared containing relevant information for responding to patient concerns, and faxed to area physicians on March 11.

The MOHLTC and PHO were also updated on the process and response to date, as well as next steps for this investigation. Key contacts from these agencies were notified on March 10 and were provided copies of the documents related to the investigation, response and media release.

Operations – Phase 3 (Response Phase)

Operations operated the call centre from March 14 through April 13 inclusive. During this final response phase of IMS, the call centre responded to individuals requesting their results, further information on testing and related concerns. Operations also hand-delivered copies of all laboratory results to RMG at their location in Fergus a minimum of once per week, but initially more frequently. On April 13, the call centre was closed and clients were referred to Clinical Services for results, questions and concerns. IMS was exited on April 13 and post-operational debriefs were prepared for forwarding to the Incident Commander.

Clinical Services

Clinical Services worked closely with Operations and performed activities to help resolve the incident. Clinical Services received all results for blood work taken as a result of the RMG incident.

As of May 2, results for 649 people have been received and followed up. Clinical Services continues to receive test results for four to six patients per day with a minimal number of telephone calls requesting testing outcome.

Planning and Surveillance

The Planning and Surveillance Section manages the collection and analysis of data.

Document Management

Early in the IMS response, a tree of folders and sub-folders was created to allow for the saving and eventual archiving of electronic documents and files related to the response. The documentation of hard copy files and documents is currently in process and is expected to continue until all important hard copy files have been submitted to the Documentation Management group leader for indexing and archiving.

Finance and Administration Section

The Finance and Administration Section manages all financial and human resources matters.

Human Resources

The role of the Human Resources group leader is to provide support for human resource policies, staff redeployment, time tracking, cost analysis and psychosocial support to staff as needs arise during an incident.

Due to the circumstances of this incident and the corrective action already taken, the RMG incident response was unique, in that the Agency had “planning time” prior to the RMG client notification and public announcement.

Generally, during these emergent events, staff respond positively and work additional hours earning compensating time off for the extra hours. This results in ongoing business continuity challenges as other work gets deferred during the response. Once the response is over, staff have accumulated additional compensating time and are not available to catch up on pending work. The decision to enter into IMS, also implemented the payment of staff at straight or overtime pay (per the Employment Standards Act of Ontario, 2000), therefore mitigating the risk of significant additional staff compensating hours.

It was anticipated that nurses and additional management hours would be required to support the call centre and administrative support would be required to document the call information given the anticipated call volume. The call centre actually experienced very low call volumes throughout the IMS period and, as such, the administrative staff were not required. The hours of operation were soon adjusted to align with normal business hours eliminating the need for additional management support for the call centre.

Call centre training took approximately 90 minutes and was provided at three different times for nurses from other divisions who volunteered or were assigned to the call centre for this event.

This event may extend for a period of six months with limited or intermittent staff time to follow-up on further client results due to the nature of the matter. Staff hours have been tracked both during their normal scheduled working hours and those beyond their normal scheduled hours.

Working hours for nurses and PHIs; management; administrative support; and porfessional support.
  Normal Scheduled Hours

Beyond Normal

Scheduled
Hour

Total

Hours

Nurses and PHIs 1284.7 125.25 1409.95
Management 398.25 75.5 473.75
Administrative Support 116 120 236
Professional Support 189.5 3.5 193
TOTALS 1988.45       324.25    2312.7

                                                                                                                  

Business Continuity

Business Continuity in the context of IMS is to ensure that critical functions the Agency must carry out are appropriately staffed and completed. Each division within the Agency has a Business Continuity Plan which identifies by priority which functions must be staffed and carried out and which functions may be deferred until the crisis or incident being managed has resolved. This plan informs decisions on which staff members may be seconded to other roles and functions in the event of an emergency.

ANALYSIS/RATIONALE

The RMG IPAC lapse response was planned and delivered using an IMS structure internally. IMS is considered a best practice model for emergency response provincially and internationally.5   Early adoption of IMS allowed WDGPH to prepare in advance the communications, resources and equipment needed to respond to RMG’s client notification and WDGPH’s media release. Typically public health incidents and/or emergencies occur quickly and do not allow for any advanced incident specific preparation. During the complaint investigation, WDGPH seized equipment and stopped reprocessing at the RMG office. This action eliminated any ongoing risk to clients and provided an opportunity for WDGPH to plan a coordinated response internally while collaborating with partners externally. IMS section leads, specifically Communications and Operations were able to communicate and collaborate with the MOHLTC, the CPSO, RMG, PHO and the Public Health Ontario Laboratory to complete a risk assessment of the IPAC lapse, share findings and agree on the client notification and testing process. WDGPH implemented the internal IMS to plan and prepare for anticipated phases of the response. During the response, group leads continued to meet frequently to share new information, discuss and problem-solve challenges and identify needed resources.

Adopting the IMS structure early and maintaining it throughout the response kept those involved informed of the overall incident objectives and changing priorities during the different phases of the response. Although the RMG event was not a large scale public health emergency, it was a unique incident which required a large coordinated response. Using IMS served as a training/ testing opportunity for WDGPH in an effort to build capacity and prepare for a large public health emergency or community disaster.  It also tested internal business continuity plans.

Regular training of staff and testing of emergency response capacity and business continuity plans are required by the Public Health Emergency Preparedness Standard and Protocol. 

Ontario Public Health Standards

Infectious Diseases Prevention and Control Standard

Requirement #2:  The board of health shall conduct surveillance of:

  • Infectious diseases of public health importance, their associated risk factors, and emerging trends; and 
  • Infection prevention and control practices of inspected premises associated with risk of infectious diseases of public health importance in accordance with the Infectious Diseases Protocol, 2008 (or as current) and the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Requirement #7:  The board of health shall ensure that the medical officer of health or designate is available on a 24/7 basis to receive reports of and respond to infectious diseases of public health importance in accordance with the Health Protection and Promotion Act; the Mandatory Blood Testing Act; the Exposure of Emergency Service Workers to Infectious Diseases Protocol, 2008 (or as current); the Infectious Diseases Protocol, 2008 (or as current); the Institutional/Facility Outbreak Prevention and Control Protocol, 2008 (or as current); and the Public Health Emergency Preparedness Protocol, 2008 (or as current).

Requirement #9: The board of health shall ensure that the medical officer of health or designate receives reports of complaints regarding infection prevention and control practices and responds and/or refers to appropriate regulatory bodies, including regulatory colleges, in accordance with applicable provincial legislation and in accordance with the Infection Prevention and Control Practices Complaint Protocol, 2008 (or as current). In addition, if an infection prevention and control lapse is identified, the board of health shall post an Initial and a Final Report online on the board of health’s website, in accordance with the Infection Prevention and Control Practices Complaint Protocol, 2008 (or as current).

Requirement #13: The board of health shall communicate in a timely and comprehensive manner with all relevant health care providers and other partners about urgent and emerging infectious disease issues.

Public Health Emergency Preparedness Standard

Requirement #1: The board of health shall identify and assess the relevant hazards and risks to the public’s health in accordance with the Identification, Investigation and Management of Health Hazards Protocol, 2008 (or as current); the Population Health Assessment and Surveillance Protocol, 2008 (or as current); and the Public Health Emergency Preparedness Protocol, 2008 (or as current).

Requirement #2: The board of health shall develop a continuity of operations plan to sustain the ongoing functioning of time-critical board of health services during business disruptions in accordance with the Public Health Emergency Preparedness Protocol, 2008 (or as current). 

Requirement #3: The board of health shall develop its emergency response plan, in consultation with community partners and governmental bodies, to address the identified hazards for which the board of health and medical officer of health will have a lead role in responding to, consistent with an Incident Management System and in accordance with the Public Health Emergency Preparedness Protocol, 2008 (or as current).

Requirement #4: The board of health shall develop, implement, and document 24/7 notification protocols for communications with board of health staff, community partners, and governmental bodies to facilitate the sharing of information in accordance with the Public Health Emergency Preparedness Protocol, 2008 (or as current).

Requirement #5: The board of health shall, in collaboration with community partners, increase public awareness regarding emergency preparedness activities. 

WDGPH Strategic Commitment

Strategic Directions
DIRECTION APPLIES? (YES/NO)
Health Equity: We will provide programs and services that integrate health equity principles to reduce or eliminate health differences between population groups.       NO
Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.      YES
Service Centred Approach: We are committed to providing excellent service to anyone interacting with Public Health.     YES
Building Healthy Communities: We will work with communities to support the health and well-being of everyone.     YES

 

Health Equity

The medical procedures identified as presenting a low risk of infection to patients of RMG included IUD insertions and endometrial biopsies. Based on the nature of these procedures, only female patients were advised to be tested for hepatitis B, hepatitis C and HIV.  As part of orientation and training for the call centre staff, the sensitivity associated with testing for blood-borne diseases and the need to protect personal and health information was reinforced. For callers concerned with the stigma associated with the test or the test results, individual counselling and non-nominal test options were provided. Males who were indirectly affected by the client notification were not excluded and were provided the same options for testing and assurances of privacy. Callers looking for results were asked a series of questions to confirm identity before providing results.

 

Low-income individuals were not anticipated to experience inequitable hardship related to the requested testing. The blood test requested is covered by OHIP, and therefore free of charge to patients. Transportation may have been a concern of some patients, however the blood work could be done at any community or hospital laboratory. Patients were provided with contact information for 19 laboratories in the region, making testing more accessible.

Appendices

Appendix A – IMS Organizational Chart

APPENDIX A – IMS Organizational Chart

 

Appendix A IMS Organizational Chart

REFERENCES

 1. Ontario. Ministry of Health and Long-Term Care, Public Health Division. Infection Prevention and Control Lapse Disclosure Guidance Document. Toronto, ON: Queen’s Printer for Ontario; 2016. Available from:    http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/guidance/ipac_lapse_disclosure_gd.pdf

2. Ontario. Ministry of Health and Long Term Care.  Infection Prevention and Control Practices Complaint Protocol, 2015. Toronto, ON:  Queens’ Printer for Ontario; 2015. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/emergency_preparedness.pdf

3. Ontario. Ministry of Health and Long Term Care. Public Health Emergency Preparedness Standard and Protocol. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/emergency_preparedness.pdf

4. Ontario.  Ministry of Health and Long Term Care. Ontario Public Health Standards. Toronto, ON: Queens’ Printer for Ontario; 2008 [revised 2015 October]. Available from: http://health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/ophs_2008.pdf

5. Ontario.  Ministry of Community Safety Services and Correctional Services. Incident Management System (IMS) for Ontario. Toronto, ON: Queen’s Printer for Ontario; 2008. Available from: www.emergencymanagementontario.ca.