Singapore Hepatitis C outbreak: Was complacency the root cause? — Desmond Wai

DECEMBER 12 — Taking care of patients with liver diseases on a daily basis, I can fully understand the impact of hepatitis C on the patient, his or her family, as well as the national healthcare system. Naturally, I am interested in the verdict of the Independent Review Committee (IRC) on the hepatitis C outbreak at Singapore General Hospital (SGH).

It is good that neither the police nor the IRC found any evidence of foul play. I cannot imagine any rational person spreading the infection to innocent patients, willingly or unwillingly. Such culprits should be punished severely by the law.

Another positive finding is that, once the outbreak was reported to the director of Medical Services, prompt action was taken.

The Ministry of Health was also able to gather a strong team to form the committee fairly quickly. I have worked closely with many of them in the past. They are all well regarded in our field of hepatology.

What disappoints me, however, is the renal team not recognising the outbreak promptly. If they had recognised it earlier, perhaps the investigation could have started earlier and the outbreak could have been contained.

In medical school, we were taught to look for patterns and outliers. If there is a sudden increase in patients with elevated liver enzymes, we should start asking why.

If we are not sure, we could always ask for help from other specialists.

It is also worrying that several cases of non-compliance in infection control protocols were identified. When we break rules, we put our patients’ health, as well as our own, at risk.

This leads me to wonder if we have been too complacent. We should always be prepared for the unknown unknowns, such as an outbreak. That things have not happened does not mean they will never happen.

Improving the procedures

Administrators can do a lot to minimise the risk of an outbreak in a healthcare setting.

First, the ward workflow ought to be well thought out. “Dirty” areas must be separated from “clean” areas, and staff who handle soiled equipment should not handle patients.

Let me explain with an example. I perform endoscopies daily at the hospital endoscopy centre. Patients would enter the endocentre via the front door. After a procedure, the endoscope is often soiled with patients’ secretions and faecal materials. So used scopes are sent to a back room via the back door for cleansing. The dirty scope would not be taken out via the front door. Next patient would then come in via the front door and will not have contact with any soiled equipment.

Endoscopy staff who wash the dirty equipment do not touch patients, while nurses who attend to patients do not wash scopes. These help prevent cross-contamination.

Second, hospitals must provide means and incentives to help healthcare workers adhere to infection-control protocols. We are required to wash hands with antiseptic soap in between instances of contact with patients. So the ward ought to be equipped with water basins with soap and rubbish bins throughout.

We are required to wear full person protection equipment (PPE) when we attend to highly-infectious patients in isolation rooms, and dispose of the PPE after the consult. So wards must provide adequate and easily-accessible PPE.

Third, the administrators ought to do focus group discussion with the ground staff to find out the root cause for non-compliance.

Most infection-control protocols are well written. But why are the staff not following it? Are they too busy? Do they have too many patients or too much paperwork? Are the protocols too complex to remember?

At the endoscopy centre at my hospital, they leave a large gap in between patient appointments. We allocate 30 minutes to do a gastroscopy when, in effect, the procedure can be completed within 15 minutes. The time lag allows the staff to clear the paperwork and follow the cleaning procedures in between scopes. This way, they would not feel the need to rush to complete the tasks.

But the public should also be prepared for additional costs because of new measures implemented to ensure more stringent controls. So we ought to weigh the pros and cons as well as the cost-effectiveness of each new measure.

For example, one bottle of insulin contains 100 units. Sometimes, one patient would only require five to 10 units each time. It makes economic sense to share one bottle with several patients in the same vicinity if done in a proper way. If we ban multi-valve dosing in the ward, each patient will require one bottle. There will be wastage and an increase in cost.

There was also criticism levelled at SGH and its staff over this outbreak. We should be aware that healthcare workers are at the greatest risk when there is an outbreak.

Many studies have shown that among dialysis patients, 10 to 20 per cent may harbour chronic hepatitis C, and another 10 to 20 per cent may harbour chronic hepatitis B. These are infectious diseases that could lead to long-term liver damage.

Dialysis patients often have numerous procedures involving needles during dialysis. Healthcare workers, nurses, technicians and doctors alike are at risk of contracting these diseases from their patients.

The healthcare workers who work at the renal unit are putting their health, as well as those of their family members, at risk. The courage of the SGH Renal Unit nurses ought to be applauded.

This outbreak reminds me of the Black Swan theory and the Weakest Link game. A Black Swan event is one that was unprecedented and unexpected at the time of occurrence. If we keep seeing white swans in the park, we may be in shock when a black swan appears. But this outbreak reminds us to be prepared for any unexpected events in our healthcare system. And we are only as good as our weakest link. Even if we have the best surgeons and technologies in our healthcare system, our patients suffer and our reputation gets damaged when even one small mistake occurs.

* Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.

** This is the personal opinion of the writer or publication and does not necessarily represent the views of Malay Mail Online.

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