What is the survey report at the Saitama hospital, the largest cluster in Japan

What was happening at the hospital in Toda City, Saitama Prefecture, where the largest cluster in Japan occurred, with more than 320 infected and 45 dead?

When I got the investigation report, I found that hospital staff were eating while talking in the break room, and because they were wearing protective clothing, they had more chances to touch the surface with the virus when putting on and taking off. According to an interview with the people concerned, it was pointed out that the infection may have spread.

At Toda Chuo General Hospital in Toda City, Saitama Prefecture, the infection spread after a nurse's infection was discovered in November last year, and by last month, a total of 324 people, including 174 employees and 150 patients, were infected, of which 45 were. Died and became the largest cluster in the country.

In January, a cluster countermeasure group of the Ministry of Health, Labor and Welfare was dispatched to investigate the infection status and causes, and compiled a report.

According to a report obtained by NHK, the infection spread to 11 of the 15 wards, and more than half of the infected were staff.

There are 127 infected nurses, which means that about one in four hospital nurses has been infected.

Regarding the cause of the spread of the infection, it was difficult for the staff to have a meal while talking with each other in the break room, to talk without wearing a mask in the changing room, and to put a mask on the patient. I mention that there were some people.

In addition, as a measure to prevent infection, there were cases where nurses and others wore thin protective clothing in layers, and it was pointed out that the infection may have spread because the chances of touching the surface to which the virus had adhered increased when putting on and taking off. I did.

In addition, as the infection spreads, it is not possible to know who is the close contact person at the site, and sufficient information is not given to the staff who came in support instead of the staff who were on standby at home. Problems were also pointed out.

Dr. Yoji Harada, director of Toda Chuo General Hospital, said, "We take it seriously that a large-scale cluster has occurred. The number of patients has increased rapidly, exceeding the capacity to accept patients, and we have to see other patients in the general ward. I'm sorry for the patient and the deceased. "

Layering of protective clothing may have led to the spread of infection

As a countermeasure against the infection of the new coronavirus, medical professionals usually wear thin protective clothing that is easy to move and deal with patients.

According to a report compiled by the Cluster Countermeasures Group of the Ministry of Health, Labor and Welfare, there were cases where Toda Chuo General Hospital wore protective clothing to prevent infection, but it may have led to the spread of infection. It has been pointed out.

According to the hospital, in some wards, it was decided at the site that layering protective clothing would help prevent infection.

Why is layering of protective clothing leading to the spread of infection?

We asked the person in charge of the hospital in Saitama City to explain with a demonstration.

The most important thing to be careful about when handling protective clothing is to put it on and take it off without touching the outer surface where the virus may be attached.

For this reason, it is common to disinfect hands and fingers each time the surface of protective clothing is touched, and be careful when putting on and taking off.

However, layered clothing takes time to put on and take off, increases the chances of touching the surface to which the virus is attached, and increases the number of times it touches the face, increasing the risk of infection.

The person in charge at this hospital said, "I understand that I want to stack several sheets to prevent infection, but it is safer to wear one properly and disinfect my hands and fingers properly. Make sure to put on and take off protective clothing properly. However, it leads to my own safety and the safety of hospitals and patients, so I need to do it correctly. "

Expert "Insufficient measures overlapped"

Nurse Haruyo Sakaki, who is familiar with infectious disease control and is a member of the Saitama Prefecture expert meeting, said about the large cluster at Toda Chuo General Hospital, "There was no definitive reason, and the break room. It is thought that it became a mega-cluster due to the combination of inadequate measures such as meals and the handling of protective clothing in Toda. I think it can happen at other medical institutions. "

On top of that, the spread of the infection among the staff exhausted the entire hospital, and as a result, the response such as sharing information of close contacts among the staff tended to be delayed, creating a vicious circle. I'm trying to find out.

Mr. Sakaki said, "By reviewing the basic infection countermeasures once again, reducing the number of people who are close contacts among the staff as much as possible, and reducing the number of people who leave the site, the entire medical institution will not malfunction. It is necessary to proceed with such a posture. "

Death from nosocomial infection Bereaved family "Don't waste your mother's death"

The bereaved family of a woman who died after being infected with the new coronavirus while being hospitalized at Toda Chuo General Hospital said, "I was hospitalized for another disease instead of corona, so I thought I would never be infected with corona and would never see him again. I didn't have any. I want the hospital not to waste my mother's death. "

This January, an 88-year-old woman who died of a new coronavirus infection while in the hospital was a sign language instructor in Tokyo until seven or eight years ago, and it is said that she was loved by local people. I will.

After that, I suffered from dementia and entered a nearby Long-Term Care Health Facility, but I needed kidney treatment and was admitted to Toda Chuo General Hospital last November.

It is said that the eldest son of a woman was not asked to measure the temperature when she entered the hospital during the hospitalization procedure, and felt uncomfortable that the temperature was measured after completing the procedure in the hospital.

The eldest son said, "I think the order is reversed at the hospitals where infection control should be done at the top level. I felt that the nursing care facility I was in was taking stricter infection control measures."

Then, about a month after admission, a cluster occurred in the hospital in December last year, and the new year began. On January 3, the doctor in charge contacted me that my mother's condition had changed suddenly.

Following a patient in the same room, the mother was also confirmed infected and died 33 hours later.

The death certificate stated that the cause of death was the new coronavirus.

Since the infection was confirmed, the eldest son could not see his mother, could not go to the crematorium, and only the remains arrived at his home.

The eldest son said, "My mother wasn't hospitalized in Corona and was supposed to come back normally. I never thought she would die this way. I want the hospital to apologize first, and what's the cause? I want you to admit that, and don't waste your mother's death. "