Introduction
The situation is getting out of control at Good Health Hospital (Tampa Bay) since the outbreak of Escherichia coli, a specie of bacteria that can be found in many daily items. The incident involved Ward 10, which is located in the second floor. A recommendation from the Centers for Disease Control and Prevention (CDC) stated that the investigation of the bacterial source must begin with the hospital kitchen as the bacterium can be transmitted through contaminated vegetables and delicatessen meats (e.g. salami and other cold cuts). The Epidemiological Summary provides a brief description of the data obtained.
Environmental review indicated that hospitals in Tampa Bay have been known to have cases of contamination in the past, indicating that the Tampa Bay County Health Department (TBCHD) may get involved in the further investigation of the present case.
Moreover, the severity of the nosocomial infections involved could not rule out the possibility of further spread of outbreak within the ward area and the hospital itself. The report concluded that the outbreak came from spoiled food in the cafeteria. It recommended that alternate vending services must be obtained as current suppliers could not verify their product sanitation protocols. Perhaps no such protocol exists in fact. Compounding the situation was the legal action taken by one of the patients against the hospital, which needs a separate investigation to determine the possibility of pre-admission symptoms for coliform infection. This legal action may become a precedent of more from other patients infected or not for valid or invalid reasons.
This case study reviews the epidemiological findings of the investigation conducted on the current E. coli outbreak, reviews potential litigation issues associated, recommends policy and protocol improvements, and devises a draft implementation plan, including a safety protocol itinerary designed for public area posting.
Epidemiological Summary
Past Year Events
In the past 12 months, the report indicated no previous outbreaks of E. coli occurred in Good Health Hospital. However, such lack of report must be further verified.
Demographic Profile based on Specific Epidemiological Parameters
Although six cases were initially suspected, only four patients were actually infected in the nosocomial incident with ages ranging from 21 to 42. The four patients with E. coli infection were equally divided on the basis of their gender with no perceivable pattern noted based on their age. However, the youngest patient (age 21) was male, while the oldest patient (age 42) was female. As of this writing, there is no report to confirm their race or ethnicity. The outbreak involved Ward 10 on the second floor. However, there is, as of this writing, no confirmed specific time and date identified on the first onset of infection.
Severity of Infection
While E. coli bacteria are known for their drug-resistant strains, it has not been established in the report whether or not the outbreak involved antibiotic-resistant E. coli bacteria. However, since the cases were described as “severe”, it indicates a strong likelihood of antibiotic-resistant E. coli strains, which had been found to cause 73.1 percent mortality of infected patients even in the absence of organ failure (Sakellariou, et al., 2016).
Proposed Questions on Potential Litigation Issues
PQ 1 - Hospital Liability on the Infected Cafeteria Food
The general mission of hospitals is disease prevention and health and wellness promotion (Lesser & Lucan, 2013). Thus, hospitals have a stake in the quality of food being served in its cafeteria. Moreover, the health damage, resulting from the selling of unhealthy foods in the cafeteria, is also indefensible. In fact, as a role model of health for patients, visitors, and staff, hospitals must set standards of high quality in the nutritional offerings (Lesser & Lucan, 2013) because food service is the extension and a strong symbol of its engagement with communities they are serving. Ultimately, patients (and other individuals in direct physical contact with patients) have no conscious deliberation for food choices sold in the cafeteria. Thus, infected foods are an accountability of the cafeteria and, by extension, the hospital. While there is a clear ethical issue involved, legal liability may be indefensible. It is recommended (#1) that Good Health Hospital must review its selection standards for cafeteria operators to ensure high quality and food safety.
PQ 2 - Hospital Liability on its Failure to Stop the Infectious Outbreak
Being bastions of health care, hospitals are expected to be capable practitioners of good infection control (Borden Ladner Gervais, 2008). Thus, the inability of a hospital, like the Good Health Hospital, to stop the infectious E. coli outbreak indicates its failure to install a reliable infection control practice. In this case, however, the number of infections constitutes an outbreak, according to the CDC definition of at least two cases (Bisgard, 2000). In effect, hospitals are expected not to wait till two new cases of E. coli infection occurs in patients without prior infection before hospitalization. It is recommended (#2) that the hospital revise its current alert guidelines on nosocomial outbreaks to require a single incidence of nosocomial infection as urgent for thorough investigation with an objective of stopping the infection from causing more infections either directly from the source or from spreading through contact transmission.
PQ 3 - Hospital Liability on the Role of Health Care Workers in Spreading the Infection
Health care workers, including student trainees, represent the fiduciary obligation of hospitals to their patients. While the involvement of healthcare workers cannot be ruled out in this case due to earlier cases of E. coli outbreaks without potential association with cafeteria food offerings, failure of the hospital staff to observe infection prevention measures, which can be validly interpreted as intentional non-compliance, will redound negatively as a liability of Good Health Hospital. A study in Australia indicated that doctors have the poorest (71%) rate of hand hygiene compliance (Hand Hygiene Australia, 2015). It is recommended (#3) that the hospital infection control protocols and policies be reviewed and, when necessary, reworded carefully to be easily understood, widely communicated, and regularly implemented (Samut, 2016).
PQ 4 - Hospital Liability on its Failure to Prevent the Infectious Outbreak
Nosocomial infections, unlike years ago, are now perceived as preventable events (Samut, 2016; Borden Ladner Gervais, 2008). Thus, any infectious outbreak in a hospital, like the Good Health Hospital, can be logically attributed to the failure of the hospital to establish reliable infection prevention practices, exposing it to vicarious liability for negligence or intentional health care worker failures to comply with infection control protocols (e.g. unwashed hands are a major route for bacterial transmission) (Samut, 2016). The same recommendation in PQ3 will be necessary in this proposed question.
PQ 5: Hospital Liability for Hospitalization Acquired Infection
Hospitals are expected to treat the disease of hospitalized patients, not to cause disease on hospitalized patients. Moreover, nosocomial infection has associated cost to infected patients. These infections, for instance, can lead to extended hospitalization and the consequent increase in treatment and diagnostic costs (Samut, 2016). In effect, nosocomial infection is a clear liability of the hospital where it occurs. Thus, it is recommended (#4) that the Good Health Hospital voluntarily inform infected patients that treatment of nosocomial infection be on the hospital’s account, better to include the treatment of hospitalization disease to absolve liability.
PQ 6: Hospital Liability for Mental Anguish of Notified Uninfected Patients
A significant quantity of class actions had been filed over claims from uninfected patients for suffering harm (e.g. mental distress) as a consequence of getting notified for possible infection (Borden Ladner Gervais, 2008). Even non-patients had filed such claims. To avoid this risk, it is recommended (#5) that the administration must exercise restraint in informing uninfected patients on their infection risks (Borden Ladner Gervais, 2008) by the E. coli outbreak. Instead, preventive measures (e.g. room transfer) must be implemented to correct the potential spreading of infection as a practical alternative to the pursuit of ‘over-notification’.
Implementation Plan
Internal Target Audience
The target audience are health care workers with direct contact with the patients and patient visitors as well as other hospital workers with direct contact with patient visitors.
Implementation steps
Step 1, Review of current infection control policy and protocols – The Good Health Hospital must review its existing infection control policy and protocols in accordance with the recommendations indicated with the proposed questions. This review includes a critical deliberation of other measures that can further improve impact from recommendations.
Step 2, Enhance and rewrite current infection control policy and protocols – With better options identified, the infection control policy and protocols must be revised to reflect best practices generated from the recommendations and review deliberations. The new policy and protocols must include compliance measures to quickly detect non-compliance among target audiences, tailored to their respective proximity and contact level with patients and visitors.
Step 3, Healthcare worker information drive – An administrative team tasked at implementing the new infection control policy and protocols must conduct a thorough information drive with the target audience to ensure clear understanding and support.
Step 4, Implementation and feedback – The implementation of the new infection control policy and protocols takes place with a feedback mechanism from the target audience for best practice comments and suggestions. These suggestions will be used in the next review session.
Safety Protocol Itinerary
The recommendation-based safety protocol itinerary for public posting includes:
(1) Safety Protocol for Health Care Personnel: All healthcare workers who are in direct physical contact with patients must follow the required hand hygiene protocol before and after care contact with their patients.
(2) Safety Protocol for Non-Healthcare Personnel: Non-healthcare workers, such as cafeteria attendants, who have potential direct physical contact with hospital personnel and visitors must follow the required hand hygiene protocol before and after each contact with their respective clients.
Conclusion
The recently concluded report apparently needs more data and information (e.g. drug-resistance type of the E. coli bacteria involved, date and time of outbreak onset, the ethnicity of the infected patients, etc.) that may be crucial in the effective infection control policy making and protocol revision. Several weaknesses, such as an inadequate outbreak warning mechanism, must be thoroughly investigated to ensure that blind areas are identified and corrected.
References
Bisgard, K. (2000, April). Chapter 11 – Definitions. CDC.gov. Retrieved from: https://www.cdc.gov/pertussis/outbreaks/guide/downloads/chapter-11.pdf.
Borden Ladner Gervais. (2008, November 26). Nosocomial infections: A changing legal landscape. Lexology.com. Retrieved from: http://www.lexology.com/library/detail.aspx?g=af8dae3e-4ea9-4cef-a52b-9b6c9a96c446.
Hand Hygiene Australia. (2015, March). National data period 1. HHA.org.au. Retrieved from: http://www.hha.org.au/LatestNationalData/national-data-2015.aspx.
Lesser, L.I. & Lucan, S.C. (2013, April). The ethics of hospital cafeteria food. Virtual Mentor, 15(4), 299-305.
Sakellariou, C., Gürntke, S., Steinmetz, I., Kohler, C., Pfeifer, Y., et al. (2016). Sepsis caused by extended-spectrum beta-lactamase (ESBL) – Positive K. pneumonia and E. coli: Comparison of severity of sepsis, delay of anti-infective therapy and ESBL genotype. PLoS ONE, 11(7), e0158039 (1-13).
Samut, R. (2016, August 16). Hospital-acquired infections – When are hospitals legally liable? Lexology.com. Retrieved from: http://www.lexology.com/library/detail.aspx?g=8101368d-77b6-44ad-bda4-f34d4cecf4e4.
