- Email: [email protected]
Food-borne disease in hospitale: Prevention in a changing food service environment
G.A. Gellert, MDCY, MPH M. Tormey, MPH G. Rodriguez, RS G. Brougher, RS D. Dassey, MD, MPH C. Pate, RS Los Angeles, California
The results of an investigation into an outbreak of food-borne disease at a hospital in Los Angeles County are reported. The outbreak occurred at a luncheon buffet for nonpatient visitors attending an event at the hospital, which was catered by the hospital. The food source and etiologic agent(s) responsible for the outbreak were not identified by our investigation. However, several issues relating to the changing character of hospital food provision and their implications for prevention of food-borne disease in hospitals were conspicuous. Two trends apparent in hospital food service are toward increased use of foodstuffs prepared by wholesale food manufacturers and more frequent invitation to community groups to meet within hospital facilities and use hospital catering services. We found that (1) hospital kitchens in Los Angeles County are undersurveyed with respect to frequency of sanitary inspections; (2) hospitals have no mechanism whereby to assess the sanitary inspection record of wholesale food manufacturers from whom they purchase foodstuffs; and (3) crossover of food items prepared for nonpatient hospital visitors, including catered foods, to the inpatient menu occurs. The potential risks for a food-borne disease outbreak among compromised inpatients resulting from these factors are discussed. and measures to reduce such risk are proposed. (AM J INFECT
CONTROL
1989; 17: 136-40)
Outbreaks of food-borne disease in hospital populations have been described in the literature.‘-14 In England and Wales reports of hospital food-borne disease are not uncommon; of the 191 outbreaks reported in institutions in 1983,37 (19%) occurred in hospitals.” Furthermore, hospitals in these nations are the setting
From the Los Angeles and the UCLA School Supported Services.
by the
County Department of Public Health.
Los Angeles
County
of Health Department
Services of Health
Reprint requests: George Gellert, MDCM, MPH, Acute Communicable Disease Control, Department of Health Services, County of Los Angeles, 313 N. Figueroa St., Room 231, Los Angeles, CA 90012.
136
for approximately one. third of all~reported outbreaks of SuZmoneUa food-borne disease occurring outside the home.16 The etiologic agents and food sources responsible for hospital food-borne illness are multiple. Frequently isolated or suspected organisms include Staphylococcus aureus, other Salmonella and Shigella species, and Clostridium perfdngens.3. 4, IO. II. 13 Commonly suspected foods are poultry, eggs, dairy products, beef, and vegetables.‘, 5*l’s l8 The potential morbidity and mortality resulting from food-borne illness in the compromised patient population of hospitals have been of concern to both hospital infection control units and state health facilities regulators. Le-
Volume June
17 Number
3
1989
gal guidelines and regulations for sanitary food preparation and delivery exist,19-** and hospital kitchens are inspected by state or local sanitarians concurrent to the accreditation review conducted by the Joint Commission on Accreditation of Healthcare Organizations.23 In addition, the Joint Commission requires that hospitals conduct self-inspections periodically between accreditation reviews as part of ongoing quality assurance.23 Participation in the Joint Commission review is voluntary. Increasingly, it appears that hospitals are inviting health-related interest groups within the community to use hospital facilities as a resource for meetings and to engage in activities not directly related to hospital patient care.24 Liaisons of this kind are beneficial to hospitalcommunity relations, and they serve to generate revenue for hospitals. In many instances a hospital not only will provide a conference site but will cater food for the eventF4 Hospitals are increasingly involved in food provision services to nonpatient populations beyond those services typically rendered in the visitors’ cafeteria. As a result hospitals are increasingly using the services of wholesale food providers, that is, importing prepared foods rather than preparing food items from their own ingredients. This practice is more economical than food preparation in the hospital kitchen and is a response to a shortage of personnel trained in hospital food preparation.24, 25 We report a suspected outbreak of food-borne illness among a population of nonpatient visitors attending an event catered by a Los Angeles hospital. The investigation uncovered issues relating to the changing character of hospital food provision and to prevention of food-borne illness in hospitals. A SUSPECTED OUTBREAK DISEASE IN A HOSPITAL
In March 1988 the Food and Milk and Health Facilities Divisions of the Los Angeles County Department of Health Services investigated a reported outbreak of food-borne illness among a population of nonpatient visitors attending a catered meal at a local hospital. The 330-bed hospital hosted a community meeting before which a buffet lunch was served to 90 attendees.
Food-borne disease in hospitals
137
Within 24 hours five attendees reported symptoms compatible with gastroenteritis to the infection control unit of the hospital. The buffet included five salads-fruit, carrot, pasta, broccoli, and chicken salads-bread, rolls, and prepared cakes. The hospital prepared only the rolls and the fruit, chicken, and broccoli salads. The remaining items were provided by wholesale food services. The sign-in list of attendees was obtained, and of the 90 persons signed in, 86 were contacted and 82 (90%) were surveyed. No hospital inpatients attended the buffet. Microbial cultures of food items were not possible because there was no leftover food after the buffet. None of the attendees who became ill sought medical attention for their symptoms. The Department of Health Services was notified after the symptoms had abated in most cases and therefore declined to obtain stool cultures. None of the food items on the buffet menu, with the exception of the prepared desserts, appeared on the inpatient hospital menu. However, the food services division of the hospital acknowledged that such crossover of food items from the outpatient to the inpatient menus does occur, including desserts, breads, and unopened entrees. The hospital infection control unit indicated that no infectious outbreak compatible with food-borne illness occurred among inpatients during the period when food-borne disease was reported. Of the 82 persons surveyed 27 (33%) reported symptoms of gastrointestinal upset, including vomiting (15%), diarrhea (63%), abdominal cramping (56%), nausea (41%), and subjective fever (15%). If a case is defined as those reporting two or more gastrointestinal symptoms, the attack rate was 23%; if a case includes any vomiting, diarrhea, or cramping, the attack rate was 29%. Of the latter group 78% reported symptoms within 8 hours of consuming the food served at the buffet, with 41% reporting discomfort between 4 and 8 hours after consumption. Forty-eight percent of patients experienced symptoms for 24 to 72 hours after onset, with half of these cases resolving within 48 hours. It was not possible to determine a specific food item responsible for the suspected out-
138
American INFECTION
Geliert et al.
break of food-borne disease. The pattern of symptom onset and duration does not correspond with any single known etiologic agent, and speculation is nonproductive because (1) multiple causative agents may have been involved, resulting in uncharacteristic patterns of symptom onset and duration; (2) person-toperson spread of infection may have occurred, obscuring a recognizable pattern; and (3) poor recall of consumed items may have resulted in failure to identify an infectious food source. It is not uncommon that the microbial and/or food origins of food-borne disease remain unidentified after investigation.3’ 5.6, l3 CNAN@NNb WM30 EEUVtcEE PREVENTION OF -TAL
AN0
PO@bBOlWEDtliBASE
Outbreaks of food-borne disease in hospitals have important ramifications for prevention in this context. Food-borne disease among the inpatient population of a hospital could dramatically increase mortality. Patients predisposed to infection by surgical interventions or by medical interventions such as immunosuppressive agents or steroids, or predisposed to superinfection, could suffer serious sequelae as a result of the normally self-limited course of foodborne disease. Pediatric and elderly patients are particularly susceptible to serious morbidity from food-borne disease.13, I7 The potential for an increased case fatality rate from hospital food-borne disease justifies stringent food sanitation practices. Our investigation revealed potential problems in hospital food delivery. Commercial food establishments (e.g., restaurants) in Los Angeles County are inspected by sanitarians on an annual basis (1.7 unscheduled, unannounced inspections per year for 1986-1987)F6 The importance of regular, frequent inspections to the maintenance of sanitary standards in commercial food establishments is widely recognized:, 27.28 The Food and Drug Administration recommends that inspections be held at least every 6 months.22 Inspections have two important, interrelated effects. Restaurant owners and operators are motivated to comply with regulations and to maintain sanitary food preparation and storage practices when annual in-
Journal CONTROL
of
spection is anticipated. Furthermore, the skills and knowledge of professional sanitarians often will uncover unsanitary practices that the lay operator may not perceive. This applies no less to hospital food services. Indeed, a survey in England and Wales found that 1119 of 1660 haspita1 kitchens inspected were below sanitary standards, with 153 (13.6%) having sufficiently serious infractions to warrant prosecution.*’ It seems inappropriate therefore that hospital kitchens, to comply with Joint Commission requirements, undergo sanitary inspections by an outside agency only once every 3 years. Concurrent to the voluntary Joint Commission accreditation review, the State of California Licensing and Certification Division performs a mandatory hospital-wide inspection, a component of which is evaluation of sanitation of food service areas, and this may be true in other states as well. These inspections are previously announced, unlike those of commercial food establishments. Although hospitals are required by the Joint Commission to self-inspect routinely as a component of quality assurance, these inspections do not effect the same two interrelated results of commercial inspections. First., compliance with regulations is not stimulated because internal inspections normally have no power to ensure implementation of recommendations. Second, these inspections are carried out by persons who are not trained sanitarians; therefore neither additional skill nor professional knowledge is provided during these selfinspections. Hospital dietary services and infection control committees have contributed to the generally high level of sanitary food preparation in these facilities. However, the frequency of hospital sanitary inspections should at least equal that of commercial food establishments (i.e., annually). As hospitals increasingly offer facilities for community functions, provision of food services will expand. Hospitals will use greater quantities and more varied kinds of foods, produced by wholesale food industries, to meet catering demands. From 1968 to 1977 at least 20 outbreaks of bacterial food-borne illness were traced to mishandling or improper processing in meat or poultry plants in the United States.30
Volume June
17 Number
3
Food-borne
1989
Wholesale food manufacturing facilities are inspected by local health departments at a rate of 3.1 inspections per year per facility in 19861987.3l Correction of sanitary infractions is enforced at the local level. Certain manufacturers repeatedly fail, then correct, sanitary standards, remaining marginally within the law. It has been suggested that hospital kitchen supervisors should enforce the same policies for food handling by outside caterers or suppliers as they do within their own institutions’ or that food service operators in general should periodically inspect their wholesale suppliers.** Although these approaches may not be practical, in view of the serious consequences of diseasecausing foods entering hospitals it may be advisable to assist hospitals in selecting wholesale food manufacturers. Providing hospitals with the results of sanitary inspections of particular food manufacturers for a prior 3-year period is warranted. The sanitary record of a manufacturer could thus be a factor in hospital selection of foodstuffs. Other methods by which hospitals could differentiate between average and superior manufacturers with respect to sanitary practice should be considered. Food items in the suspected outbreak did not cross over into the inpatient menu. Such crossover does, however, frequently occur. A report of Shigellu-caused food-borne disease among 1490 hospital staff members concluded that the epidemic was limited by the fact that food for inpatients was prepared in separate areas by different personnel. l4 As hospitals increasingly provide food services to nonpatients, they will require the services of more manufacturers from whom they can purchase foods that meet the flexible and diverse diets of healthy consumers. As a result a greater array of food products and providers will appear in hospitals. Buffets and other catered events are particularly conducive settings for poor sanitary practices that promote bacterial growth and food-borne disease. In view of these factors the elimination of crossover of food items that have been ordered or prepared for nonpatients to the inpatient menu is indicated. We have described a suspected outbreak of food-borne disease in a Los Angeles hospital. Suggestions for prevention of food-borne dis-
disease in hospitals
139
ease in hospitals include (1) increasing the frequency of food sanitation inspections of hospitals from the current level of once in 3 years to an annual basis, both in the county and elsewhere where triannual hospital accreditation review provides the only kitchen inspection, (2) creating a mechanism whereby hospitals include the food sanitation inspection record as a criterion in selecting wholesale food manufacturers (providing results of inspections for the previous 3 years on request), and (3) eliminating crossover of food items from catered and other nonpatient functions to the inpatient menu. We thank Department assistance.
S. Pruhs and H. Woo of the Los Angeles County of Health Services Library for their invaluable
ROfWMBCOS
1. Pether JVS, Caul EO. An outbreak of food-borne gastroenteritis in two hospitals associated with a Norwalklike virus. J Hyg (Lond) 1983;91:343-50. 2. Baddour LM, Garia SM. Griffin R, et al. A hospital cafeteria-related food-borne outbreak due to Bacillus cereus: unique features. Infect Control 1986:7(9)462-S. G, Hamilton WI, Gould JDM, et al. An 3. Kumarasinghe outbreak of Salmonella muenchen infection in a specialist paediatric hospital. J Hosp Infect 1982;3:341-4. 4. Thomas M, Noah ND, Male GE, et al. Hospital outbreak of Clostridium perfrngens food-poisoning. Lancet 1977; 1:1046-8. 5. Sharp JCM, Collier PW, Gilbert RI. Food poisoning in hospitals in Scotland. J Hyg (Lond) 1979;83:231-6. 6. Meyers JD, Romm FJ, Tihen WS, Bryan JA. Food-borne hepatitis A in a general hospital. JAMA 1975;231:104953. 7. Eisenstein AR, et al. An epidemic of infectious hepatitis A in a general hospital: probable transmission by contaminated orange juice. JAMA 1963;185:171-4. of food poisoning incident at Cas8. Bone FJ. Report tle Douglas Hospital. Commun Dis Scotland Wk Rep 1975;3:35. 9. Mills GA. An outbreak of food poisoning in a maternity hospital and general practitioner unit. Commun Dis Scotland Wk Rep 1976;3:4. CC Jr, et al. Prolonged hospital epidemic 10. Linnemann of salmonellosis: use of trimethoprim sulfamethoxazole for control. Infect Control 1985;6:221-5. SA, Aserkoff B, Brachman PS. Epidemic sal11. Schroeder monellosis in hospitals and institutions: a five-year review. N Engl J Med 1968;279:674-8. PMB. Food poisoning in a hospital staff canteen. 12. White J Infect 1986;13:195-8. SR, Rowe B. Investigation of outbreaks of Sal13. Palmer monella in hospitals. Br Med J 1983;287:891-3. 14. Leads from the MMWR. Shigella dysenteriae type 2 outbreak in US naval hospital. JAMA 1983;249:3012.
American
140
Gellert
et al.
INFECTION
15. Communicable Disease Surveillance Centre. Food poisoning and Salmonella surveillance in England and Wales: 1983. Br Med J 1985;291:394-6. 16. Abbott JD, Hepner ED, Clifford C. Salmonella infections in hospitals. A report from the PHLS Salmonella subcommittee. J Hosp Infect 1980;1:307-14. 17. Holmberg SD, Blake PA. Staphylococcal food poisoning in the United States. JAMA 1984;251:487-9. 18. Food and Nutrition Board, Commission on Life Sciences, National Research Council. Meat and poultry inspection, the scientific basis of the nation’s program. Washington, DC.: National Academy Press, 1985. 19. California Code of Regulations; Title 22. Health facilities and referral agencies. Register 77, no 22.1977 May 28. 20. California Code of Regulations; Title 22. Health facilities and referral agencies. Register 80, no 11.1980 Mar 15. 21. California Code of Regulations; Title 22. Health facilities and referral agencies. Register 75, no 24.1975 June 14. 22. US Department of Health and Human Services, Food and Drug Administration. Food service sanitation manual. Washington, D.C.: US Government Printing Office, 1976. 23. Joint Commission on Accreditation of Healthcare Or-
Bound volumes avail&e
24. 25. 26. 27. 28.
29. 30. 31.
of
ganizations. Accreditation manual for healthcare organizations/88. Chicago: Joint Commission, 1987. Stephenson S. Hospitals forge the future. Restaurants and Institutions 1988;98(6)66-8. Stephenson S. 1988 annual forecasts for hospitals. Restaurants and Institutions 1988;98(1)98-102. Los Angeles County Department of Health Services, Program of District Environmental Services, CYA 80312-ROl, 1986-1987. Procedures to investigate foodborne illness. Ames, Iowa: International Association of Milk. Food and Environmental Sanitarians, Inc., 1987. Educational Foundation of the National Restaurant Association and the National Sanitation Foundation. Applied foodservice sanitation. 3rd ed. Dubuque, Iowa: Wm C Brown, 1985. Environmental Health Officers’ Association. Food hygiene in national health service hospitals. Press release, 1977. Bryan FC. Foodborne diseases in the United States associated with meat and poultry. J Food Protect 1980: 43:140-50. Los Angeles County Department of Health Services, Program of District Environmental Services, CYA 80302-ROl, 1986-1987.
to subscribers
Bound volumes of AMERICAN JOURNAL OF INFEXTION CONTROL are available to subscribers (only) for the 1989 issues from the Publisher, at a cost of $19.00 ($25.00 internattinal) for Vol. 17 (January-December). Shipping charges are included. Each bound volumecontains a subject and an author index. The binding is durable buclcram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany at1 orders. Contact The C.V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone 800-325-4177, ext. 351. Sa#seriptions must be in farce to qdffy. Bound~volumeo ape not avttiW fn piace of a regular jd subscxiption.
I
Journal CONTROL
I
The results of an investigation into an outbreak of food-borne disease at a hospital in Los Angeles County are reported. The outbreak occurred at a luncheon buffet for nonpatient visitors attending an event at the hospital, which was catered by the hospital. The food source and etiologic agent(s) responsible for the outbreak were not identified by our investigation. However, several issues relating to the changing character of hospital food provision and their implications for prevention of food-borne disease in hospitals were conspicuous. Two trends apparent in hospital food service are toward increased use of foodstuffs prepared by wholesale food manufacturers and more frequent invitation to community groups to meet within hospital facilities and use hospital catering services. We found that (1) hospital kitchens in Los Angeles County are undersurveyed with respect to frequency of sanitary inspections; (2) hospitals have no mechanism whereby to assess the sanitary inspection record of wholesale food manufacturers from whom they purchase foodstuffs; and (3) crossover of food items prepared for nonpatient hospital visitors, including catered foods, to the inpatient menu occurs. The potential risks for a food-borne disease outbreak among compromised inpatients resulting from these factors are discussed. and measures to reduce such risk are proposed. (AM J INFECT
CONTROL
1989; 17: 136-40)
Outbreaks of food-borne disease in hospital populations have been described in the literature.‘-14 In England and Wales reports of hospital food-borne disease are not uncommon; of the 191 outbreaks reported in institutions in 1983,37 (19%) occurred in hospitals.” Furthermore, hospitals in these nations are the setting
From the Los Angeles and the UCLA School Supported Services.
by the
County Department of Public Health.
Los Angeles
County
of Health Department
Services of Health
Reprint requests: George Gellert, MDCM, MPH, Acute Communicable Disease Control, Department of Health Services, County of Los Angeles, 313 N. Figueroa St., Room 231, Los Angeles, CA 90012.
136
for approximately one. third of all~reported outbreaks of SuZmoneUa food-borne disease occurring outside the home.16 The etiologic agents and food sources responsible for hospital food-borne illness are multiple. Frequently isolated or suspected organisms include Staphylococcus aureus, other Salmonella and Shigella species, and Clostridium perfdngens.3. 4, IO. II. 13 Commonly suspected foods are poultry, eggs, dairy products, beef, and vegetables.‘, 5*l’s l8 The potential morbidity and mortality resulting from food-borne illness in the compromised patient population of hospitals have been of concern to both hospital infection control units and state health facilities regulators. Le-
Volume June
17 Number
3
1989
gal guidelines and regulations for sanitary food preparation and delivery exist,19-** and hospital kitchens are inspected by state or local sanitarians concurrent to the accreditation review conducted by the Joint Commission on Accreditation of Healthcare Organizations.23 In addition, the Joint Commission requires that hospitals conduct self-inspections periodically between accreditation reviews as part of ongoing quality assurance.23 Participation in the Joint Commission review is voluntary. Increasingly, it appears that hospitals are inviting health-related interest groups within the community to use hospital facilities as a resource for meetings and to engage in activities not directly related to hospital patient care.24 Liaisons of this kind are beneficial to hospitalcommunity relations, and they serve to generate revenue for hospitals. In many instances a hospital not only will provide a conference site but will cater food for the eventF4 Hospitals are increasingly involved in food provision services to nonpatient populations beyond those services typically rendered in the visitors’ cafeteria. As a result hospitals are increasingly using the services of wholesale food providers, that is, importing prepared foods rather than preparing food items from their own ingredients. This practice is more economical than food preparation in the hospital kitchen and is a response to a shortage of personnel trained in hospital food preparation.24, 25 We report a suspected outbreak of food-borne illness among a population of nonpatient visitors attending an event catered by a Los Angeles hospital. The investigation uncovered issues relating to the changing character of hospital food provision and to prevention of food-borne illness in hospitals. A SUSPECTED OUTBREAK DISEASE IN A HOSPITAL
In March 1988 the Food and Milk and Health Facilities Divisions of the Los Angeles County Department of Health Services investigated a reported outbreak of food-borne illness among a population of nonpatient visitors attending a catered meal at a local hospital. The 330-bed hospital hosted a community meeting before which a buffet lunch was served to 90 attendees.
Food-borne disease in hospitals
137
Within 24 hours five attendees reported symptoms compatible with gastroenteritis to the infection control unit of the hospital. The buffet included five salads-fruit, carrot, pasta, broccoli, and chicken salads-bread, rolls, and prepared cakes. The hospital prepared only the rolls and the fruit, chicken, and broccoli salads. The remaining items were provided by wholesale food services. The sign-in list of attendees was obtained, and of the 90 persons signed in, 86 were contacted and 82 (90%) were surveyed. No hospital inpatients attended the buffet. Microbial cultures of food items were not possible because there was no leftover food after the buffet. None of the attendees who became ill sought medical attention for their symptoms. The Department of Health Services was notified after the symptoms had abated in most cases and therefore declined to obtain stool cultures. None of the food items on the buffet menu, with the exception of the prepared desserts, appeared on the inpatient hospital menu. However, the food services division of the hospital acknowledged that such crossover of food items from the outpatient to the inpatient menus does occur, including desserts, breads, and unopened entrees. The hospital infection control unit indicated that no infectious outbreak compatible with food-borne illness occurred among inpatients during the period when food-borne disease was reported. Of the 82 persons surveyed 27 (33%) reported symptoms of gastrointestinal upset, including vomiting (15%), diarrhea (63%), abdominal cramping (56%), nausea (41%), and subjective fever (15%). If a case is defined as those reporting two or more gastrointestinal symptoms, the attack rate was 23%; if a case includes any vomiting, diarrhea, or cramping, the attack rate was 29%. Of the latter group 78% reported symptoms within 8 hours of consuming the food served at the buffet, with 41% reporting discomfort between 4 and 8 hours after consumption. Forty-eight percent of patients experienced symptoms for 24 to 72 hours after onset, with half of these cases resolving within 48 hours. It was not possible to determine a specific food item responsible for the suspected out-
138
American INFECTION
Geliert et al.
break of food-borne disease. The pattern of symptom onset and duration does not correspond with any single known etiologic agent, and speculation is nonproductive because (1) multiple causative agents may have been involved, resulting in uncharacteristic patterns of symptom onset and duration; (2) person-toperson spread of infection may have occurred, obscuring a recognizable pattern; and (3) poor recall of consumed items may have resulted in failure to identify an infectious food source. It is not uncommon that the microbial and/or food origins of food-borne disease remain unidentified after investigation.3’ 5.6, l3 CNAN@NNb WM30 EEUVtcEE PREVENTION OF -TAL
AN0
PO@bBOlWEDtliBASE
Outbreaks of food-borne disease in hospitals have important ramifications for prevention in this context. Food-borne disease among the inpatient population of a hospital could dramatically increase mortality. Patients predisposed to infection by surgical interventions or by medical interventions such as immunosuppressive agents or steroids, or predisposed to superinfection, could suffer serious sequelae as a result of the normally self-limited course of foodborne disease. Pediatric and elderly patients are particularly susceptible to serious morbidity from food-borne disease.13, I7 The potential for an increased case fatality rate from hospital food-borne disease justifies stringent food sanitation practices. Our investigation revealed potential problems in hospital food delivery. Commercial food establishments (e.g., restaurants) in Los Angeles County are inspected by sanitarians on an annual basis (1.7 unscheduled, unannounced inspections per year for 1986-1987)F6 The importance of regular, frequent inspections to the maintenance of sanitary standards in commercial food establishments is widely recognized:, 27.28 The Food and Drug Administration recommends that inspections be held at least every 6 months.22 Inspections have two important, interrelated effects. Restaurant owners and operators are motivated to comply with regulations and to maintain sanitary food preparation and storage practices when annual in-
Journal CONTROL
of
spection is anticipated. Furthermore, the skills and knowledge of professional sanitarians often will uncover unsanitary practices that the lay operator may not perceive. This applies no less to hospital food services. Indeed, a survey in England and Wales found that 1119 of 1660 haspita1 kitchens inspected were below sanitary standards, with 153 (13.6%) having sufficiently serious infractions to warrant prosecution.*’ It seems inappropriate therefore that hospital kitchens, to comply with Joint Commission requirements, undergo sanitary inspections by an outside agency only once every 3 years. Concurrent to the voluntary Joint Commission accreditation review, the State of California Licensing and Certification Division performs a mandatory hospital-wide inspection, a component of which is evaluation of sanitation of food service areas, and this may be true in other states as well. These inspections are previously announced, unlike those of commercial food establishments. Although hospitals are required by the Joint Commission to self-inspect routinely as a component of quality assurance, these inspections do not effect the same two interrelated results of commercial inspections. First., compliance with regulations is not stimulated because internal inspections normally have no power to ensure implementation of recommendations. Second, these inspections are carried out by persons who are not trained sanitarians; therefore neither additional skill nor professional knowledge is provided during these selfinspections. Hospital dietary services and infection control committees have contributed to the generally high level of sanitary food preparation in these facilities. However, the frequency of hospital sanitary inspections should at least equal that of commercial food establishments (i.e., annually). As hospitals increasingly offer facilities for community functions, provision of food services will expand. Hospitals will use greater quantities and more varied kinds of foods, produced by wholesale food industries, to meet catering demands. From 1968 to 1977 at least 20 outbreaks of bacterial food-borne illness were traced to mishandling or improper processing in meat or poultry plants in the United States.30
Volume June
17 Number
3
Food-borne
1989
Wholesale food manufacturing facilities are inspected by local health departments at a rate of 3.1 inspections per year per facility in 19861987.3l Correction of sanitary infractions is enforced at the local level. Certain manufacturers repeatedly fail, then correct, sanitary standards, remaining marginally within the law. It has been suggested that hospital kitchen supervisors should enforce the same policies for food handling by outside caterers or suppliers as they do within their own institutions’ or that food service operators in general should periodically inspect their wholesale suppliers.** Although these approaches may not be practical, in view of the serious consequences of diseasecausing foods entering hospitals it may be advisable to assist hospitals in selecting wholesale food manufacturers. Providing hospitals with the results of sanitary inspections of particular food manufacturers for a prior 3-year period is warranted. The sanitary record of a manufacturer could thus be a factor in hospital selection of foodstuffs. Other methods by which hospitals could differentiate between average and superior manufacturers with respect to sanitary practice should be considered. Food items in the suspected outbreak did not cross over into the inpatient menu. Such crossover does, however, frequently occur. A report of Shigellu-caused food-borne disease among 1490 hospital staff members concluded that the epidemic was limited by the fact that food for inpatients was prepared in separate areas by different personnel. l4 As hospitals increasingly provide food services to nonpatients, they will require the services of more manufacturers from whom they can purchase foods that meet the flexible and diverse diets of healthy consumers. As a result a greater array of food products and providers will appear in hospitals. Buffets and other catered events are particularly conducive settings for poor sanitary practices that promote bacterial growth and food-borne disease. In view of these factors the elimination of crossover of food items that have been ordered or prepared for nonpatients to the inpatient menu is indicated. We have described a suspected outbreak of food-borne disease in a Los Angeles hospital. Suggestions for prevention of food-borne dis-
disease in hospitals
139
ease in hospitals include (1) increasing the frequency of food sanitation inspections of hospitals from the current level of once in 3 years to an annual basis, both in the county and elsewhere where triannual hospital accreditation review provides the only kitchen inspection, (2) creating a mechanism whereby hospitals include the food sanitation inspection record as a criterion in selecting wholesale food manufacturers (providing results of inspections for the previous 3 years on request), and (3) eliminating crossover of food items from catered and other nonpatient functions to the inpatient menu. We thank Department assistance.
S. Pruhs and H. Woo of the Los Angeles County of Health Services Library for their invaluable
ROfWMBCOS
1. Pether JVS, Caul EO. An outbreak of food-borne gastroenteritis in two hospitals associated with a Norwalklike virus. J Hyg (Lond) 1983;91:343-50. 2. Baddour LM, Garia SM. Griffin R, et al. A hospital cafeteria-related food-borne outbreak due to Bacillus cereus: unique features. Infect Control 1986:7(9)462-S. G, Hamilton WI, Gould JDM, et al. An 3. Kumarasinghe outbreak of Salmonella muenchen infection in a specialist paediatric hospital. J Hosp Infect 1982;3:341-4. 4. Thomas M, Noah ND, Male GE, et al. Hospital outbreak of Clostridium perfrngens food-poisoning. Lancet 1977; 1:1046-8. 5. Sharp JCM, Collier PW, Gilbert RI. Food poisoning in hospitals in Scotland. J Hyg (Lond) 1979;83:231-6. 6. Meyers JD, Romm FJ, Tihen WS, Bryan JA. Food-borne hepatitis A in a general hospital. JAMA 1975;231:104953. 7. Eisenstein AR, et al. An epidemic of infectious hepatitis A in a general hospital: probable transmission by contaminated orange juice. JAMA 1963;185:171-4. of food poisoning incident at Cas8. Bone FJ. Report tle Douglas Hospital. Commun Dis Scotland Wk Rep 1975;3:35. 9. Mills GA. An outbreak of food poisoning in a maternity hospital and general practitioner unit. Commun Dis Scotland Wk Rep 1976;3:4. CC Jr, et al. Prolonged hospital epidemic 10. Linnemann of salmonellosis: use of trimethoprim sulfamethoxazole for control. Infect Control 1985;6:221-5. SA, Aserkoff B, Brachman PS. Epidemic sal11. Schroeder monellosis in hospitals and institutions: a five-year review. N Engl J Med 1968;279:674-8. PMB. Food poisoning in a hospital staff canteen. 12. White J Infect 1986;13:195-8. SR, Rowe B. Investigation of outbreaks of Sal13. Palmer monella in hospitals. Br Med J 1983;287:891-3. 14. Leads from the MMWR. Shigella dysenteriae type 2 outbreak in US naval hospital. JAMA 1983;249:3012.
American
140
Gellert
et al.
INFECTION
15. Communicable Disease Surveillance Centre. Food poisoning and Salmonella surveillance in England and Wales: 1983. Br Med J 1985;291:394-6. 16. Abbott JD, Hepner ED, Clifford C. Salmonella infections in hospitals. A report from the PHLS Salmonella subcommittee. J Hosp Infect 1980;1:307-14. 17. Holmberg SD, Blake PA. Staphylococcal food poisoning in the United States. JAMA 1984;251:487-9. 18. Food and Nutrition Board, Commission on Life Sciences, National Research Council. Meat and poultry inspection, the scientific basis of the nation’s program. Washington, DC.: National Academy Press, 1985. 19. California Code of Regulations; Title 22. Health facilities and referral agencies. Register 77, no 22.1977 May 28. 20. California Code of Regulations; Title 22. Health facilities and referral agencies. Register 80, no 11.1980 Mar 15. 21. California Code of Regulations; Title 22. Health facilities and referral agencies. Register 75, no 24.1975 June 14. 22. US Department of Health and Human Services, Food and Drug Administration. Food service sanitation manual. Washington, D.C.: US Government Printing Office, 1976. 23. Joint Commission on Accreditation of Healthcare Or-
Bound volumes avail&e
24. 25. 26. 27. 28.
29. 30. 31.
of
ganizations. Accreditation manual for healthcare organizations/88. Chicago: Joint Commission, 1987. Stephenson S. Hospitals forge the future. Restaurants and Institutions 1988;98(6)66-8. Stephenson S. 1988 annual forecasts for hospitals. Restaurants and Institutions 1988;98(1)98-102. Los Angeles County Department of Health Services, Program of District Environmental Services, CYA 80312-ROl, 1986-1987. Procedures to investigate foodborne illness. Ames, Iowa: International Association of Milk. Food and Environmental Sanitarians, Inc., 1987. Educational Foundation of the National Restaurant Association and the National Sanitation Foundation. Applied foodservice sanitation. 3rd ed. Dubuque, Iowa: Wm C Brown, 1985. Environmental Health Officers’ Association. Food hygiene in national health service hospitals. Press release, 1977. Bryan FC. Foodborne diseases in the United States associated with meat and poultry. J Food Protect 1980: 43:140-50. Los Angeles County Department of Health Services, Program of District Environmental Services, CYA 80302-ROl, 1986-1987.
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Bound volumes of AMERICAN JOURNAL OF INFEXTION CONTROL are available to subscribers (only) for the 1989 issues from the Publisher, at a cost of $19.00 ($25.00 internattinal) for Vol. 17 (January-December). Shipping charges are included. Each bound volumecontains a subject and an author index. The binding is durable buclcram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany at1 orders. Contact The C.V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone 800-325-4177, ext. 351. Sa#seriptions must be in farce to qdffy. Bound~volumeo ape not avttiW fn piace of a regular jd subscxiption.
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