The Too Long; Didn’t Read version of the Hepatitis C saga that happened in SGH. The full report by the Independent Review Committee can be viewed here.
In October, SGH announced that 25 patients in its renal ward had contracted the Hep C virus, and subsequently lodged a police report. 7 have passed on due to the virus. The hospital has since screened hundreds of patients and staff through contact tracing, following the discovery of the cluster.
This led to the formation of the Independent Review Committee (IRC) appointed by the Ministry of Health (MOH) to look into the incident.
Police investigations have ruled out foul play as a possible cause for the incident.
Independent Review Committee (IRC) Report
Cause of Outbreak
- The wards, 64A and 67, had mainly kidney transplant patients whose immune systems were compromised. The affected patients had medication administered to them through needles and had their blood taken, exposing them to hepatitis C through gaps in infection control and cleaning of equipment.
- Breaches in infection control may have been accentuated by the temporary move of the renal ward from 64A to 67, where the layout was different from what staff were familiar with.
Reporting of Incident
- There was a delay in reporting to its infection control unit for help in containment. The committee found a delay in escalation of the matter from SGH to its parent SingHealth and to the ministry because of the absence of an established framework for the unfamiliar and unusual event of the hepatitis C outbreak.
- HEP C is not easily detected as the incubation period for hepatitis C is 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms.
- SGH was focused on putting in place infection control measures before escalating to MOH, as it was working within the existing workflow where the management of healthcare-associated infections is the responsibility of the hospital, and that SGH was taking responsibility before informing MOH.
- The committee said there was no evidence to suggest that the escalation of the matter to MOH and subsequent notification of Health Minister Gan Kim Yong on Sept 18 had been deliberately delayed.
Investigations and Management of Incident
- Incomplete investigations were done initially by SGH and only a complete investigation was only done after SGH met with MOH on Sept 3. MOH had to ask for additional investigation and action to be undertaken within the next two weeks after that meeting.
- The committee added that when faced with the uncommon and unfamiliar event of an HCV cluster, SGH showed a lack of clarity on roles and responsibilities for the management of such infection outbreaks.
Recommendations to Prevent Future Incidents
- The committee has called on 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.
- SGH should 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.
- SGH to strengthen the monitoring and supervision framework for staff to ensure compliance to SOPs.
- For the national notification and surveillance system for acute Hep C to be improved, taking references from best practices in other countries.
- To designate a team within MOH to carry out surveillance, identify and investigate potential outbreaks, and ensure adequate expertise
nationally for investigations.
- Hospitals should continue to take responsibility and develop structures, frameworks and capabilities for Healthcare associated infections outbreaks. Where required, the hospital’s capabilities can be supplemented with additional resources from the national healthcare system.
Thoughts on the whole saga…
It is extremely unfortunate that this has happened and our hearts go out to the victims and their families. This incident could have been avoided with better preventive measures.
The review was fair and balanced. At the end of the day even the best practices are subject to the lowest common denominator. Human beings adhering to (or conversely, short-cutting), procedures. It seems like both a training and a discipline issue with regard to the staff. Management has also to take responsibility for this lack of discipline. Although there was no cover up per se, more might have been done to identify the issue earlier on in SGH. But having done and said that, it is often very difficult to see a trend that occurs over a period of time (as opposed to a sudden virulent outbreak).
Hopefully the hospital will learn from this and the report help bring closure to the families of the victims. Some compensation to the families would be a appropriate gesture on the part of SGH.