Safe

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Safe Unsafe Hospital KitchensAn Outbreak
Perspective

• Quentin Ruscoe
• Health Protection Officer
• Disease Investigation
• Regional Public Health

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RPH OUTBREAK INVESTIGATION

• Aim To minimise public health impact of enteric
  disease outbreaks
• Identify source of outbreak
• Stop further infections
• Reduce risk of future similar outbreaks
• Work with industry towards good public health
  outcomes
• Address public concern
• We investigate food safety hazards, we dont
  audit kitchens

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2006 Which? Survey UK Hospital Kitchens

• Hygiene inspection reports, 3 years, 50 NHS
  hospitals
• Frequent problems
• - dirty equipment
• - cockroach infestations
• - no soap or hot water for personal hygiene
• - poor refrigeration

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Cont.

• Some hospitals
• - food fridges used for medical supplies
• - out-of-date foods
• - failed food safety procedures

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Hospital food hasnt got the best reputation,
but youd expect the kitchens to be clean at the
very least. Unfortunately, weve found this
isnt always the caseEditor Which?- NHS
Hospitals
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Quick Goggle 1995-2005 Overseas Hospital
Foodborne Outbreaks

• All hospital types affected
• In various developed countries including
  Australia
• Largish numbers of cases, some deaths
• Patients also staff infected
• Typical pathogens Salmonella, E.coli 0157H7,
  Listeria monocytogenes, norovirus

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NZ Hospital Foodborne Outbreaks
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Any More .?

• Several serious infections in continuing care
• - seemingly sporadic cases
• - pathogen foodborne by default
• - some fatal (e.g. Listeria monocytogenes)
• Problems in well-run kitchens!
• - smoked chicken contaminated with L.
  monocytogenes served to pregnant women
  immunocompromised
• Foodborne illness still relevant nosocomial issue

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NZ 2006 All Outbreaks Setting (ESR data)

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RPH Outbreak Investigation
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Ideal Situation

• Know involved pathogen at start
• Good idea of implicated food(s)
• Can visit premises focus on likely hazards
• Have leftover food to sample
• Can quickly identify source of contamination
• THIS TIMELINE RARELY OCCURS!

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Reality

• General idea of outbreak
• Pathogen unknown / guessed
• Suspect food(s) unknown
• May need to visit premises immediately
• RISK TO PUBLIC HEALTH?

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1ST Premises Investigation

• Joint visit with TLA
• Obtain staff profile
• Use checklist to scan the following
• Staff Personal Incoming Food
  Cross Environmental
• sickness hygiene goods storage
  contamination hygiene cleaning

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Causes of Food Poisoning

• Preparing food too far in advance
• Storing food at ambient temperatures
• Cooling food too slowly before refrigeration
• Not reheating food to sufficient temperatures
• Using contaminated food

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Cont.

• Undercooking meat poultry
• Ineffective thawing of frozen poultry meat
• Cross contamination between raw cooked food
• Keeping hot food lt60oC
• Infected food handlers

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Infected Food Handlers

• Cause large outbreaks, e.g. norovirus, HAV
• Human nature!
• Written staff sickness policy
• Records
• Enforce specific exclusions
• NZFSA template

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Cross-Contamination

• Outbreak eg, Campylobacter, Salmonella
• Between raw RTE foods
• Many pathways
• - cleaning cloths do travel
• - drips in refrigerated storage
• - unsanitised preparation areas
• - same-use utensils boards
• - food touched in service

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Using Contaminated Food

• E.g. norovirus outbreaks Korean oysters
• Contaminated growing waters
• Oysters filter feeders accumulate viruses
• Labelled to be cooked not eaten raw
• Labels unread oysters served raw
• Human error in several restaurants

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Time / Temperature Abuse (1)

• Common cause of food poisonings
• Outbreaks e.g. Bacillus cereus Clostridium
  perfringens
• Bacteria grow best between 4 60oC
• This is the DANGER ZONE
• Never keep food in DZ for gt2 hours
• Improperly stored food cant be made safe by
  reheating as some bacteria produce heat resistant
  toxins

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Time / Temperature Abuse (2)

• Preparing storing foods
• Cooking foods
• Cooling hot foods
• Displaying perishable foods
• Reheating foods

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2nd Premises Investigation

• Follows up checklist information
• May now know / suspect pathogen
• May now have suspect implicated food(s)
• - from 1st inspection
• - from stats analysis of menu
• May now suspect particular hazard
• Examine food process using HACCP

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What is HACCP?

• HACCP is identifying all the ingredients and
  steps in making a food product, identifying where
  problems can occur fixing them before they
  become a problem!
• FARM TO FORK

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Principles of HACCP

• Identify (M,C,P) hazards eliminate where can
• Identify critical control points (CCPs) for
  remaining hazards
• Specify criteria to ensure control at CCPs
• Establish monitoring for CCPs
• Take corrective action when monitoring criteria
  not met
• Verify that above system is working as planned
• Keep suitable records to show process always
  controlled

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Principle 1 Identification of hazards

• Identify microbial (chemical physical) hazards
• Use a risk assessment methodology to determine
• - risk i.e. probability of hazards occurring
• - severity i.e. seriousness of outcomes when
  hazards occur
• See if hazards can be eliminated / reduced to
  acceptable safe level

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Principle 2 Determine Critical Control Points

• Control Points are points in food processing
  where it is possible to control or remove
  hazards.
• BUT
• Critical Control Points are control points in
  food processing where it is essential to control
  a hazard, usually because there is no later step
  at which to establish control.

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Principle 3 Establish Critical Limits

• Critical limits for CCPs are measurements such
  as temperature or time, that must be met, or
  characteristics such as food appearance and
  texture.

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Principle 4 Establish Monitoring System

• Monitoring is the regular measurement or
  observation of a CCP to ensure it is not beyond
  its critical limits.
• Monitoring must ensure any loss of control at
  CCP can be discovered in time to take
  corrective action before
  product is rejected.
• Usually simple time / temperature records
  sufficient

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Principle 5 Establish Corrective Action

• Take Corrective Action to bring process back
  under control before problem leads to food safety
  hazard.
• If cannot, reprocess or dump affected food

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HACCP Us You!

• RPH (other PHUs) investigate food poisoning
  outbreaks using HACCP approach
• You can use HACCP to ensure food is safely
  produced in your facilities kitchens
• Develop a written Food Safety Plan

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Food Safety Regulation For You (1)

• Currently
• Inspection licensing by some TLAs (if have By
  Laws) under Food Hygiene Regulations
  (structural)
• or
• Optional development of Food Safety Plan
• - assessed by PHUs
• - approved by NZFSA

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Food Safety Regulation For You (2)

• July 2008
• Mandatory Food Control Plans
• For all public private hospitals, rest homes,
  hospices, maternity homes, meals on wheels, etc
  (see Domestic Food Review)
• FSPs will be off the peg templates under
  trial
• ? assessors TLAs or PHUs

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Food Safety Regulation For You (3)

• Hospitals with Food Safety Plans
• (A) Eurest / Compass Group
• - 6 hospitals with approved FSPs
• (B) Spotless Services
• - 6 hospitals with approved FSPs

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ANY QUESTIONS?