SGH Hep C cluster: Measures to improve infection control, response mooted
SINGAPORE: The Independent Review Committee (IRC) convened to investigate the Hepatitis C virus (HCV) cluster at Singapore General Hospital (SGH) on Tuesday (Dec 8) outlined recommendations to improve infection control and the national response system to such events.
The IRC’s recommendations followed its 79-page report, which was accepted by the Ministry of Health (MOH). The report identified breaches in infection control as a likely cause of the HCV cluster, where seven people died, and also highlighted flaws in the system response to unusual and unfamiliar outbreaks.
The committee, which was set up in late September and which included international experts, said there was a need for SGH to review existing standard operating procedures (SOPs) and practices on infection control, to further reduce the risk of contamination of medical equipment and contact surfaces, as well as to ensure adequate environmental cleaning and disinfection.
Specific measures included designating a clean area for the preparation of intravenous medication, using washable keyboard covers, not touching surfaces on computerised medical carts with contaminated or gloved hands, and considering the option of using fluorescent dye to assess the adequacy of cleaning.
The committee also recommended that SGH ensure staff adhere to standard precautions for infection control, and adopt best practices such as those laid out in guidelines from the US Centres for Disease Control and Prevention (CDC) - but adapted to the Singaporean context.
For instance, the hospital should consider the use of needleless intravenous devices, to allow safe injection of medication without the use of needles. CDC guidelines also include the appropriate use of single-dose and multi-dose vials.
SGH should strengthen its monitoring and supervision framework for staff to ensure compliance to SOPs, said the review committee. It added that SGH should prepare a plan for corrective measures specific to the findings identified by the IRC.
"This plan should be formulated within one month and submitted to MOH for review, to ensure patient and healthcare worker safety, and maintain a high standard of patient care with particular attention to infection control," the committee said in its report.
The IRC comprised of the following members:
Prof Leo Yee Sin (Chairman) - Director and Clinical Director, Tan Tock Seng Hospital
Prof Lim Seng Gee - Senior Consultant, Division of Gastroenterology and Hepatology, Department of Medicine at the National University Hospital (NUH)
Assoc Prof Helen Oh - Head of Infectious Diseases at Changi General Hospital (CGH)
Dr Titus Lau - Senior Consultant, Division of Nephrology at NUH
Ms Paulin Koh - Chief Nurse at CGH
Assoc Prof Quek Swee Chye - Deputy Chairman of the Medical Board at NUH
Dr Jeffrey Cutter - Director (Communicable Disease Division) at MOH
Also present at the press conference on Tuesday were Assistant Professor Angela Chow, Head of the Department of Clinical Epidemiology at TTSH's Institute of Infectious Disease and Epidemiology, and Professor Tan Chorh Chuan, President of the National University of Singapore. They were appointed as resources for the IRC to tap on during the review.
RESPONSE FRAMEWORKS SHOULD BE ENHANCED
The committee also recommended that MOH to enhance its current surveillance and outbreak response frameworks to cater for unusual and unfamiliar events, for outbreak detection investigation and management, communication and escalation protocols, and the appropriate roles of MOH and the hospital in question.
The IRC suggested improving the national notification and surveillance system for acute HCV, taking reference from international best practices and adapting them to the Singaporean context.
One possibility, said the committee, is to build an electronic system where laboratories can automatically send notifications to MOH. It also said there should be a designated team within MOH to carry out surveillance, identify and investigate potential outbreaks and ensure adequate expertise nationally for investigations.
But hospitals should also continue to take responsibility and develop frameworks and capabilities for healthcare-associated infection outbreaks, it added.
Where required, the hospital’s capabilities can be supplemented with additional resources from the national healthcare system, including but not limited to infectious diseases specialists and epidemiologists.
The committee also asked MOH to strengthen its escalation and communication processes for healthcare-associated infections, especially unusual and unfamiliar ones, within and between hospitals, public healthcare clusters and MOH. This should be achieved through clearer guidelines on the assessment of the significance and severity of a healthcare-associated infection, said the IRC.
It noted that it may not be easy to set guidelines for all situations, so regardless of systems in place, healthcare professionals should be alert to escalate any event that is unfamilar and unusual. Doctors, especially, are reminded of their obligation to report instances of infectious disease, as stipulated by MOH.
When asked if MOH would convene a Committee of Inquiry (COI) as called for by the opposition Workers’ Party, the ministry said it was satisfied with the IRC’s findings and recommendations.
“We do not see a need to convene a COI to repeat what the IRC has done. What else is there to establish that the IRC has not established?” said MOH in a statement. “Our priority now is to focus efforts and resources on implementing remedial measures to improve patient safety and patient care.”
The infection has affected 25 patients at SGH’s renal ward.
- CNA/xq
