1. Pseudo Outbreak of Group A Strep (GAS) at Concord Hospital A Collaborative Review Review Participants IP, ID, Lab, Micro, QA, Materials Management, Lean, DHHS Presented by Lynda Caine, Infection Prevention Officer

2. Agenda Background Reviews Conducted – Line Listing – Process and Observation – Product Review – Case Studies and Lab Data Correlation with Timeline DHHS Reports

3. Background 8 cases of Group A Strep were identified in blood cultures over several weeks in April-May In 2013, 5 cases of GAS were reported for the entire year This could be a serious finding as GAS in the blood is a serious infection and can be fatal Occurrences are reportable to DHHS Note: all 8 cases were present on admission

4. Background continued This is a higher number of positives than our usual or expected number Concern of whether this represented a possible pseudo outbreak Decision to review all cases and blood culture process Decision to contact the State for possible assistance Were we dealing with a contamination issue or was it a coincidence?

5. Pseudo outbreak Type: Term Pronunciation: sū-dō-out′brāk Definitions: 1. Episode of increased disease incidence due to enhanced surveillance or other factor not related to the disease under study

6. Line Listing 8 symptomatic patients seen in the ED between 4/1/14 and 5/3/14 No common links were identified – except all blood cultures were drawn in the ED – No community commonalities were identified – Different room locations in ED – Different Phlebotomists drew blood – No illness of ED and Phlebotomy Staff – Patients received antibiotics after blood draw

7. Process Observation Reviewed Lab Policy Looked at all supplies used for a blood draw Looked at all of the steps in a blood draw Created a flow map of laboratory blood culture collection and processing steps One simulated blood draw observation was conducted No discrepancies identified between stated and observed practices

11. Product Review Micro conducted testing on all lots of current blood culture bottles as well as chlorhexidine swabs – with no positive results Collected a sample of all supplies used for blood culture collection Materials Management compiled a list of vendors and manufacturers – although no further action was needed at this time

12. CH Case Timeline Plotted: Blood Culture Collection Time Antibiotic Administration Blood Culture Result Time Finding: blood cultures were obtained prior to antibiotic administration

13. Lab Data Correlation Medical record review supported intermittent bacteremia or septicemia present on admission – Symptoms: including fever – Lab results: WBC, Lactic Acid, Absolute Neutrophils, etc. NOTE: Group A strep is not a typical blood culture contaminate

14. Community Data from CH Micro: Positive Group A Strep Throat Cultures

15. DHHS: Group A Strep by Age Group

16. DHHS: Group A Strep Rate and Cases by Age Group

17. DHHS: Group A Strep Cases by Sex and Year

18. DHHS: Group A Strep Cases by County and Year

19. DHHS: Group A Strep Rate by County and Year

21. DHHS: Group A Strep Rate by County

22. DHHS: Group A Strep Rate by Month

23. DHHS: Group A Strep Rate and Cases by Year

24. Summary No further cases have been identified Increased incidence of group A Strep noted in Concord and in other New Hampshire communities DHHS was not concerned but reviewed NH data Continue to monitor for new incidence Save future isolates for PFGE testing at the State Lab through June 1, 2014 Re-emphasize to Staff to not come to work when ill

25. Special THANKS to DHHS!!!