Ottawa Fertility Centre

Ottawa Public Health Infection Prevention and Control
Summary Report
for the Ottawa Fertility Centre
955 Green Valley Crescent, Unit 100
Ottawa, ON K2C 3V4
April 14, 2015
On February 26, 2015, Ottawa Public Health (OPH) was contacted by the Public Health Ontario (PHO)
Regional Infection Control Network about a potential infection control issue identified during an invited
visit by PHO staff to the Ottawa Fertility Centre (OFC), 100-955 Green Valley Crescent, Ottawa,
Ontario. The issue pertained to the use of a dishwasher for the cleaning of used medical devices and
equipment before sterilization. PHO had been invited by the clinic to review their infection prevention
and control (IPAC) practices in order to assist the clinic in meeting accreditation standards.
On March 4, 2015, as per the Infection Prevention and Control Complaint Practices Protocol of the
Ontario Public Health Standards, OPH contacted the College of Physicians and Surgeons of Ontario
(CPSO) to inform them of the potential IPAC issue. The CPSO is responsible for quality assurance in
independent health facilities, and conducts assessments as part of the Out-Of-Hospital Inspections
Program. On March 5, 2015, the CPSO requested assistance from OPH in assessing the IPAC
practices at the OFC.
On March 10, 2015, a joint CPSO assessment and OPH inspection of the OFC identified deficiencies in
IPAC practices that could potentially pose a risk of transmission of infection for the clients and staff of
the clinic, related to:
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Reprocessing (i.e. cleaning/disinfection and sterilization) of medical devices and equipment
including cleaning and disinfection of ultrasound probes
Training and certification of staff with regards to reprocessing of medical devices
Hand hygiene practices
Environmental cleaning
Availability and use of personal protective equipment (PPE)
Clinic management and staff at the OFC took immediate actions to correct IPAC deficiencies, including
the key practices of stopping the use of the dishwasher and adopting a manual cleaning protocol for all
medical instruments.
On March 23, 2015, the CPSO issued a report with a finding of “Pass with Conditions” to the OFC that
was based on the March 10, 2015, assessment/inspection. The CPSO report provided the OFC until
April 6, 2015 to provide a written response to the conditions.
On March 23, 2015, a re-inspection of the OFC was conducted by OPH to assess what corrective
actions had been addressed and to review additional IPAC practices. The clinic acknowledged
concerns with IPAC practices, their intention to address all the concerns, and had made several of the
requested changes; however, OPH observed that more changes would be required to meet IPAC best
practices, especially pertaining to on-site reprocessing of medical devices.
In a report issued on April 6, 2015, OPH recommended actions to address outstanding issues,
including that the OFC outsource all cleaning, disinfection and sterilization of medical devices until such
time as these functions can be performed on-site in accordance with IPAC best practices. Following
receipt of this written report, the OFC indicated that further changes had been made to address
concerns raised in the March 23, 2015, re-inspection.
On April 10 and 13, 2015, further re-inspections of the OFC were conducted by OPH to assess
progress in implementing the recommended changes identified throughout this process. Significant
improvements had been made for pre-cleaning and cleaning of instruments, hand hygiene practices,
environmental cleaning, and availability and use of personal protective equipment. As an interim
measure, some reprocessing steps were being undertaken by OFC staff at an external facility. OPH
considered that with some modifications, the interim reprocessing procedures were acceptable and all
IPAC concerns observed during inspections have been addressed until such time as the clinic could
complete renovations to their reprocessing area.
OPH inspection findings and recommendations with respect to infection prevention and control have
been submitted to the CPSO as well as the OFC. The CPSO has given the clinic the status of “Pass
with Conditions”. The CPSO will continue follow-up as per their policies and procedures.
For more information on this report, please contact Ottawa Public Health at 613-580-6744.
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OPH Infection Prevention and Control Summary Report for the Ottawa Fertility Centre