In 2014 STS carried out a research project on behalf of the FSA in order to draft new listeriosis guidelines.
STS are the leading food safety specialists in healthcare and therefore well positioned to undertake the listeriosis guidelines research project. As well as having assessed the NHS supply chain for food safety for over 20 years, we work with NHS Trusts, private hospitals, care homes and contract caterers in care settings nationwide.
The listeriosis project involved undertaking considerable research, upon which the new listeriosis guidelines are based. Main threads of research included:
STS adopted a collaborative approach to the listeriosis guidelines project, involving the following partners in the project team:
STS believed involvement and partnership was important in order to ensure the listeriosis guidelines were well rounded and practical.
The FSA then further consulted wider on the listeriosis guidelines draft with other stakeholders.
The listeriosis guidelines are pitched to apply both to a small care home or a large complex hospital. They not only benefit healthcare organisations by helping them to protect patients/residents from listeriosis, but also provide sensible food safety advice in general.
Previous listeriosis outbreaks
Although cases and outbreaks of listeriosis are relatively rare, the concern with listeriosis is that the fatality rate is high – approx. 30% in vulnerable groups. As a consequence, listeriosis kills more people in the UK than any other food-borne disease. Listeriosis outbreaks have occurred in hospitals, giving rise to the need for listeriosis guidelines for healthcare establishments in order to reduce the risks.
The research into previous listeriosis outbreaks in hospitals found that almost all were linked to consumption of pre-packed sandwiches. Almost all listeriosis outbreaks were thought to have been caused by low level contamination of the ingredients with Listeria monocytogenes during manufacture in the factory, followed by a breakdown in the control of the cold chain in the hospitals, leading to multiplication of Listeria monocytogenes to infective levels.
This is not to say that pre-packed sandwiches are the only product which can be affected – listeriosis has been linked to many different products, usually those which support bacterial growth and are ready to eat. Neither does this mean listeriosis is only caused by contamination of food brought in – contamination could occur in the healthcare organisation, and if time and temperature are not adequately controlled, risks could be high.
Listeriosis is caused by the bacteria Listeria monocytogenes. One of the features that make the listeriosis bacteria different from other harmful, pathogenic micro-organisms is that it can grow at low temperatures, including in a refrigerator. If high risk foods are contaminated and given enough time they can grow and multiply to harmful levels in the food, putting patients at risk.
One surprising and very significant fact that came form the research was that the rate at which the Listeria monocytogenes bacteria multiply doubles at 8°C compared to 5°C. For this reason the listeriosis guidelines encourage the cold chain to be maintained at 5°C or less. This could well give rise to CapEx considerations for health care organisations with ineffective kit.
There was concern at first from dietitians that the listeriosis guidelines should not restrict foods on the menu and, as a consequence, have an impact on nutrition. An example was in Northern Ireland where one of the most serious listeriosis outbreaks occurred, linked to consumption of pre packed sandwiches. As a consequence many hospitals were afraid and actually removed sandwiches from menus. The listeriosis guidelines do not encourage such drastic measures, with the emphasis being put on safe practice.
During research into current practices and previous outbreaks, STS found that hospitals who had experienced listeriosis outbreaks were the most exemplary in their standards – showing that tight practices are possible. We found catering managers who had experienced listeriosis outbreaks had become very knowledgeable and put excellent procedures in place to prevent recurrence.
Lessons learned from the hospitals and environmental health professionals who had dealt with previous listeriosis outbreaks were invaluable, especially those in Northern Ireland who have undertaken extensive work into prevention. The extent of the precautions in place even extend to patient locker checks by nursing staff as some cases of listeriosis have been linked to patients squirreling sandwiches away in lockers, leading to rapid multiplication of Listeria monocytogenes at room temperature.
Look wider than the catering department
STS observed that food safety is commonly seen as the responsibility of the catering department alone, however, this is most certainly not the case.
Many of the listeriosis outbreaks in hospitals have not arisen from patient catering from the main kitchen but from other sources. The listeriosis guidelines rightly bring out that Trusts/healthcare organisations needs to look at all food pathways – routes by which food can reach patients – and do what they reasonably can to make sure each pathway is safe. In the light of this guidance STS urges Trusts and other healthcare organisations to examine the food pathways which exist within their operation and ensure they are addressed in their organisational-wide food safety policy, taking into consideration the listeriosis guidelines.
One example of a food pathway is sandwiches purchased in retail outlets, including those run by voluntary organisations. Onsite contractors and retailers may not have the same standards in terms of procurement, temperature control etc as the main catering operations.
Other food pathways include food which is brought in for patients by relatives or volunteers. The listeriosis guidelines provide sensible advise which can be taking into consideration when developing such policies.
Over the years, STS has found that food safety within a hospital catering department is often at a high standard, and it can be at ward level where food safety can come unravelled, especially where food service is dependent on staff outside the catering team e.g. housekeepers, domestics or nursing staff. Of course there are wards where food service is exemplary, but STS has observed that too often responsibilities are blurred, or bad practices are observed.
As recently as the last few weeks, Fiona Sinclair from STS recalls observing sandwiches left at room temperature in ward kitchens, sandwiches which are past their use by date, and sandwiches placed in pantry fridges holding above 8°C. Such practices are unacceptable when providing food for vulnerable groups, and should be a thing of the past.
Why does this happen? Food service at ward level is often the responsibility of departments and staff for whom food is not a primary role and, sometimes, there is less awareness of the fundamental acceptable/unacceptable practices which are the norm for a member of the catering team. Furthermore at ward level, responsibilities for disposal of out of date food, checking fridge temperatures etc can sometimes be blurred amongst departments which leads to them falling between the gaps.
STS’s Fiona Sinclair says: “Catering managers regularly express frustration and concern about what happens when the food leaves the control of the catering department. We very much hope that these guidelines will be the catalyst to consistently raising food safety standards across the UK at ward level and that it will become more and more common to see the food safety culture extending into food service.”
The fact that Listeria monocytogenes double in number twice as fast at 8°C than 5°C is significant as, in our experience, hospitals and care homes often have domestic fridges in ward/pantry/kitchenettes.
Fiona Sinclair says: “It is not uncommon to find fridges struggling to hold temperatures even at 8°C or below – the legal maximum. Just because a small satellite kitchen used for food service is termed a pantry or kitchenette, it does not mean that domestic standards are acceptable – it is unacceptable to store high risk foods such as sandwiches and salads in fridges which do not maintain temperature.”
Some Trusts and homes will need to invest in maintaining the cold chain to address such issues.
The thought that a loved one should lose their life from eating a sandwich in hospital is ridiculous. The new listeriosis guidelines which have been released are a helpful step towards raising awareness of the problem and taking sensible preventative measures to reduce the risk of listeriosis. It’s trusted that healthcare organisations will find the guidance helpful in understanding the risks, and incorporating safe measures into their management systems.