No evidence patients were informed of hospital-acquired SABSI in three sites

There was no documentary evidence in a group of hospitals that patients were informed they had acquired a Staphylococcus aureus bloodstream infection (SABSI) during their hospital stay, according to a recent HSE internal audit report.

The hospitals are Galway University Hospitals (GUH); the Mater Misericordiae University Hospital (MMUH), Dublin; and Midland Regional Hospital, Tullamore (MRHT).

The objective of the audit was to determine the level of assurance that could be provided to management related to the use of review tools (RTs) for hospital-acquired SABSI.

The audits covered SABSI diagnoses and incident reporting/disclosure in the calendar year 2022.

All three audited hospitals had evidence of a governance framework which underpinned their responsibilities in relation to monitoring of hospital-acquired infections.

While there was documentary evidence that hospital-acquired SABSI was discussed at senior hospital management level at two sites, this was not evident at GUH.

GUH and MRHT used the agreed procedure and the associated RT to guide processes in relation to review of hospital-acquired SABSI; however, they did not complete reviews following incidents.

MMUH did not use the procedure or the associated review tool. MMUH used a document titled ‘Hospital acquired bacteraemia flowpath’ (2016) for review of hospital-acquired SABSI.

“This flowpath did not refer to an analysis of hospital-acquired SABSI in a manner that was consistent with the RT and the HSE Incident Management Framework (2020), nor did it refer to the disclosure of incidents of hospital-acquired SABSI in a manner that was consistent with the HSE Open Disclosure Policy,” according to the HSE internal audit activity report for the third quarter of 2023. The report, which was presented to the audit and risk committee in November, was obtained by Medical Independent (MI) through Freedom of Information law.

Risk assessments that included all commonly known risks related to hospital-acquired SABSI were not evident at any of the three sites.

“There was no documentary evidence at the three sites audited that patients were informed that they had a hospital-acquired SABSI, that a review would be undertaken, or that the results of any reviews were shared with the patient in line with the HSE Open Disclosure Policy and the procedure,” according to the document.

Hospital-acquired SABSI was not recorded on any of the discharge summaries reviewed at the three sites.

GUH and MRHT logged some, but not all, incidents of hospital-acquired SABSI on the national incident management system (NIMS).

MMUH did not log any incidents of hospital-acquired SABSI on to NIMS during the timeframe examined by the audit.

However, MMUH stated that incidents of hospital-acquired SABSI are recorded on a MMUH incident form and are uploaded on to the NIMS, with effect from January 2023.

When asked for an update on the audit recommendations, a spokesperson for the HSE told MI: “Of the 28 recommendations accepted, 23 have been reported as implemented, with the remaining five in progress.”