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Source: http://www.thespec.com/BreakingNews/article/436677
Out of Control: Part III Fatal C. difficile outbreak flew under Jo Brant's radar
September 16, 2008
Naomi Powell
The Hamilton Spectator
Enid Mackay's appetite disappeared overnight.
Suddenly, the feisty 91-year-old, who'd always walked to meals in her retirement home, couldn't stomach food and couldn't find the strength to dress in the morning.
"She couldn't even stand up," said Carole Partington, who'd watched her mother take regular walks at Joseph Brant Memorial Hospital to rehabilitate her broken hip. "I tried to explain to the nurse, 'No, that's not what she's like.' "
Her belly distended, her body fighting bouts of uncontrollable diarrhea, MacKay died on Aug. 30, 2006. C. difficile directly contributed to her death.
Though no one knew it yet, an outbreak of the deadly superbug had already been ravaging Jo Brant for four months. By the time its deadly tour was finished, 177 patients were infected and 91 died.
Yet it wasn't until January 2007 -- eight months after the first infected patient died in May 2006 -- that senior hospital administrators realized something was wrong.
Still another 10 months would pass before the hospital publicly declared an outbreak.
For families who lost loved ones, the question remains: What took so long?
It was a gastroenterologist who first alerted Jo Brant to the growing C. difficile problem.
"In January '07, it came to our attention that something different was happening with C. difficile in the hospital," Jo Brant CEO Don Scott told The Spectator in June, weeks after the paper launched an investigation into the outbreak at the lakeside hospital. "We began to see an increased number of C. difficile cases and people dying from C. difficile, which was very unusual."
The hospital put stiffer infection control practices into place and the infection rates seemed to go back to normal. But by May, the number of cases had surged again.
Still more measures were ordered.
"And again, we saw initially that it seemed to come under control," Scott said.
It was not to last. Through July, August and September, the infection rates rose again. This time their climb would not be abated.
The hospital alerted the Halton Public Health Department at the end of September, and in November they both turned to Dr. Michael Gardam, an infectious disease expert at Toronto's University Health Network, to help get a handle on the outbreak.
His findings, released in May, 2008, were stunning: The outbreak had started seven months earlier and was four times deadlier than Jo Brant had thought.
"I think the one thing people have had a very, very difficult time understanding and coming to grips with is the fact that it took so long for us to recognize that we had an outbreak in the hospital," Scott said. "And it did take a period of time to find out we had an outbreak."
Spotting and managing outbreaks is a tricky enterprise. Hospitals need to have an idea of how many C. difficile infections are normal in order to know when something's gone wrong. A key tool is a so-called baseline, or estimate of the typical number of infections in a hospital at a given time. By comparing the current number of infections to the baseline, hospitals assess whether an outbreak is under way and if action is necessary to bring the situation under control.
The trouble was, when Jo Brant's outbreak began in 2006, the hospital didn't have a baseline for C. diff infections, Gardam said. Following the gastroenterologist's alert, Jo Brant attempted to set a baseline by looking back through its data to a month showing what seemed to be a normal number of cases.
But by not going back far enough, they missed the real start of the outbreak.
"The trick is that depending what you take as your baseline, you may think things are OK," Gardam said. "But if you go back far enough, the baseline they were using wasn't their baseline. They needed to go back earlier in time."
When he set about establishing the hospital's proper baseline, Gardam went way back. Following several stable months in early 2006, the rate "jumped up" in May.
"It jumped up and bopped around but it never went back to what it was before."
Gardam doesn't believe the hospital was trying to hide anything.
"I think they just didn't realize it."
At the time, no one required hospitals to set a baseline for infectious diseases, he points out, and there were no official guidelines for how to do it.
The central document for managing C. diff -- a best practices paper designed by the Provincial Infectious Diseases Advisory Committee -- defines an outbreak as when the number of C. diff cases exceeds the hospital's baseline. It does not, however, offer any instructions on how hospitals might establish that baseline.
"There are no guidelines at all," said Gardam, who says Jo Brant isn't the only Ontario hospital operating without a C. diff baseline.
"Please let us notice that most other places are just like them," Gardam said. "That message needs to get out."
C. diff was not a reportable disease when Jo Brant's outbreak occurred and hospitals tended to keep their infection rates to themselves, making it impossible to compare rates among institutions.
Ontario hopes to remedy such issues when hospital infection rates start flowing into the province's mandatory reporting system on Sept. 26. The data will provide points of comparison for hospitals to help establish baselines.
It will also establish guidelines for what constitutes an outbreak and when public health should be notified.
But at the time of the outbreak, Jo Brant was operating in isolation.
"I think we were in a void," Don Scott told The Spectator in June. "We didn't know how our rates compared to other hospitals. We had no idea."
There were other things that made Jo Brant's outbreak tough to spot. For one thing, it didn't emerge the way many outbreaks do: as a cluster of infections on a specific floor or ward of a hospital.
The C. diff cases at Jo Brant were scattered throughout the building, making the bug's advance difficult to notice.
And it didn't help that Jo Brant's infection control team was operating on reduced staff. Though the hospital now employs three full-time infection control practitioners, at points during the outbreak the staff was reduced by half, said Anne Bialachowski, network co- ordinator for Jo Brant's regional infection control committee.
What's more, the hospital's long-time infection control manager had retired, leaving the management of hospital infections to less experienced staff.
"For two years they had a lack of experienced (infection control practitioners) there," Gardam said.
These days, the floors inside Jo Brant bear a blackish stain, a side effect of the sporicidal agent the hospital now uses in its daily cleaning. On Gardam's recommendation, it has switched from bleach to the sporicidal agent -- a less toxic and corrosive product that can be used all over a room to remove C. diff spores.
The hospital has set up aggressive housekeeping and handwashing regimes to bring C. diff under control. It is keeping a close watch on the use of antibiotics thought to make patients more vulnerable to the bug.
An official end to the outbreak was declared in June, more than two years after the first deaths occurred. But the tragedy has left its scars on the small hospital.
"It can be devastating to the team of health care professionals," Scott said. "They're here to promote and extend life. To have this happen on their watch or on their duty is devastating to them.
"They are trying to do their best under difficult circumstances and there is a challenge: How do we learn from this and grow from it?"
The scars are deeper for the families.
"At 91, you figure it's nature taking its course," said Carole Partington, of her mother Enid MacKay. "But if this hadn't happened and she had just passed away from natural causes, you would have said, she was 91, she had a good life. But when it happens this way, you think she got robbed of a few years, whether she wanted them or not.
"So it does leave you very bitter. I don't know if there's any anger. I think bitter is the better word."
Scott declined to discuss specific details of the outbreak, citing a $50-million class action lawsuit filed by families of those who died in the outbreak.
Out of Control: Part III Fatal C. difficile outbreak flew under Jo Brant's radar
September 16, 2008
Naomi Powell
The Hamilton Spectator
Enid Mackay's appetite disappeared overnight.
Suddenly, the feisty 91-year-old, who'd always walked to meals in her retirement home, couldn't stomach food and couldn't find the strength to dress in the morning.
"She couldn't even stand up," said Carole Partington, who'd watched her mother take regular walks at Joseph Brant Memorial Hospital to rehabilitate her broken hip. "I tried to explain to the nurse, 'No, that's not what she's like.' "
Her belly distended, her body fighting bouts of uncontrollable diarrhea, MacKay died on Aug. 30, 2006. C. difficile directly contributed to her death.
Though no one knew it yet, an outbreak of the deadly superbug had already been ravaging Jo Brant for four months. By the time its deadly tour was finished, 177 patients were infected and 91 died.
Yet it wasn't until January 2007 -- eight months after the first infected patient died in May 2006 -- that senior hospital administrators realized something was wrong.
Still another 10 months would pass before the hospital publicly declared an outbreak.
For families who lost loved ones, the question remains: What took so long?
It was a gastroenterologist who first alerted Jo Brant to the growing C. difficile problem.
"In January '07, it came to our attention that something different was happening with C. difficile in the hospital," Jo Brant CEO Don Scott told The Spectator in June, weeks after the paper launched an investigation into the outbreak at the lakeside hospital. "We began to see an increased number of C. difficile cases and people dying from C. difficile, which was very unusual."
The hospital put stiffer infection control practices into place and the infection rates seemed to go back to normal. But by May, the number of cases had surged again.
Still more measures were ordered.
"And again, we saw initially that it seemed to come under control," Scott said.
It was not to last. Through July, August and September, the infection rates rose again. This time their climb would not be abated.
The hospital alerted the Halton Public Health Department at the end of September, and in November they both turned to Dr. Michael Gardam, an infectious disease expert at Toronto's University Health Network, to help get a handle on the outbreak.
His findings, released in May, 2008, were stunning: The outbreak had started seven months earlier and was four times deadlier than Jo Brant had thought.
"I think the one thing people have had a very, very difficult time understanding and coming to grips with is the fact that it took so long for us to recognize that we had an outbreak in the hospital," Scott said. "And it did take a period of time to find out we had an outbreak."
Spotting and managing outbreaks is a tricky enterprise. Hospitals need to have an idea of how many C. difficile infections are normal in order to know when something's gone wrong. A key tool is a so-called baseline, or estimate of the typical number of infections in a hospital at a given time. By comparing the current number of infections to the baseline, hospitals assess whether an outbreak is under way and if action is necessary to bring the situation under control.
The trouble was, when Jo Brant's outbreak began in 2006, the hospital didn't have a baseline for C. diff infections, Gardam said. Following the gastroenterologist's alert, Jo Brant attempted to set a baseline by looking back through its data to a month showing what seemed to be a normal number of cases.
But by not going back far enough, they missed the real start of the outbreak.
"The trick is that depending what you take as your baseline, you may think things are OK," Gardam said. "But if you go back far enough, the baseline they were using wasn't their baseline. They needed to go back earlier in time."
When he set about establishing the hospital's proper baseline, Gardam went way back. Following several stable months in early 2006, the rate "jumped up" in May.
"It jumped up and bopped around but it never went back to what it was before."
Gardam doesn't believe the hospital was trying to hide anything.
"I think they just didn't realize it."
At the time, no one required hospitals to set a baseline for infectious diseases, he points out, and there were no official guidelines for how to do it.
The central document for managing C. diff -- a best practices paper designed by the Provincial Infectious Diseases Advisory Committee -- defines an outbreak as when the number of C. diff cases exceeds the hospital's baseline. It does not, however, offer any instructions on how hospitals might establish that baseline.
"There are no guidelines at all," said Gardam, who says Jo Brant isn't the only Ontario hospital operating without a C. diff baseline.
"Please let us notice that most other places are just like them," Gardam said. "That message needs to get out."
C. diff was not a reportable disease when Jo Brant's outbreak occurred and hospitals tended to keep their infection rates to themselves, making it impossible to compare rates among institutions.
Ontario hopes to remedy such issues when hospital infection rates start flowing into the province's mandatory reporting system on Sept. 26. The data will provide points of comparison for hospitals to help establish baselines.
It will also establish guidelines for what constitutes an outbreak and when public health should be notified.
But at the time of the outbreak, Jo Brant was operating in isolation.
"I think we were in a void," Don Scott told The Spectator in June. "We didn't know how our rates compared to other hospitals. We had no idea."
There were other things that made Jo Brant's outbreak tough to spot. For one thing, it didn't emerge the way many outbreaks do: as a cluster of infections on a specific floor or ward of a hospital.
The C. diff cases at Jo Brant were scattered throughout the building, making the bug's advance difficult to notice.
And it didn't help that Jo Brant's infection control team was operating on reduced staff. Though the hospital now employs three full-time infection control practitioners, at points during the outbreak the staff was reduced by half, said Anne Bialachowski, network co- ordinator for Jo Brant's regional infection control committee.
What's more, the hospital's long-time infection control manager had retired, leaving the management of hospital infections to less experienced staff.
"For two years they had a lack of experienced (infection control practitioners) there," Gardam said.
These days, the floors inside Jo Brant bear a blackish stain, a side effect of the sporicidal agent the hospital now uses in its daily cleaning. On Gardam's recommendation, it has switched from bleach to the sporicidal agent -- a less toxic and corrosive product that can be used all over a room to remove C. diff spores.
The hospital has set up aggressive housekeeping and handwashing regimes to bring C. diff under control. It is keeping a close watch on the use of antibiotics thought to make patients more vulnerable to the bug.
An official end to the outbreak was declared in June, more than two years after the first deaths occurred. But the tragedy has left its scars on the small hospital.
"It can be devastating to the team of health care professionals," Scott said. "They're here to promote and extend life. To have this happen on their watch or on their duty is devastating to them.
"They are trying to do their best under difficult circumstances and there is a challenge: How do we learn from this and grow from it?"
The scars are deeper for the families.
"At 91, you figure it's nature taking its course," said Carole Partington, of her mother Enid MacKay. "But if this hadn't happened and she had just passed away from natural causes, you would have said, she was 91, she had a good life. But when it happens this way, you think she got robbed of a few years, whether she wanted them or not.
"So it does leave you very bitter. I don't know if there's any anger. I think bitter is the better word."
Scott declined to discuss specific details of the outbreak, citing a $50-million class action lawsuit filed by families of those who died in the outbreak.