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Most hospitals not complying with HSE screening guidance on CPE – HIQA inspections

Seven inspection reports on infection prevention and control practices in public acute hospitals have today been published by HIQA. The Authority monitors infection prevention and control practices in hospitals against national standards for the prevention and control of healthcare-associated infections in acute healthcare services.

These inspections represent the first to have been conducted by HIQA following the declaration on 25 October by Minister for Health Simon Harris of a National Public Health Emergency in relation to CPE, which disable the carbapenem class of antibiotics or the ‘drugs of last resort’ for life-threatening infections.

The HSE introduced CPE screening guidelines for the acute hospital sector in June 2017. These were further updated in February 2018, with additional screening requirements to be implemented in all hospitals from 1 March 2018.

Given the critical importance of this measure, HIQA was “very concerned” to find that only two hospitals out of the seven inspected in the first three months of 2018 were in full compliance with the HSE CPE screening guideline that was current at the time of the inspection.

As the threat associated with CPE has been declared a national public health emergency, HIQA considered this to be “a significant risk to patients and in all cases escalated concerns to the hospitals and the HSE to seek assurances around how each hospital might ensure compliance with the HSE’s own guidelines”.

HIQA’s inspections were carried out between January and March 2018 at Midland Regional Hospital Tullamore; Portiuncula University Hospital; Cappagh National Orthopaedic Hospital, Dublin; St Vincent’s University Hospital, Dublin; South Infirmary Victoria Hospital, Cork; Royal Victoria Eye and Ear Hospital, Dublin; St James’s Hospital, Dublin.

In each of the five hospitals that were not meeting the HSE’s guidelines, measures to address the gap identified by HIQA were proposed.

“It is a public health imperative that all required measures to address the CPE issue are both quickly and universally implemented by the HSE. It is HIQA’s intention to continue to monitor hospitals to ensure that these measures are implemented over the coming months,” stated the Authority.

Further details relating to specific findings from each of the seven inspections are outlined below.

Midland Regional Hospital Tullamore, Co Offaly:

An unannounced inspection of Midland Regional Hospital, Tullamore, took place on 30 January 2018.

The hospital had not successfully ensured that screening patients for CPE was fully embedded in line with national HSE guidelines. HIQA escalated concerns related to this finding to the hospital in writing following the inspection. Hospital management responded by highlighting key actions which the hospital has instigated to address this risk.

Inspectors found that governance and management arrangements around the prevention and control of healthcare-associated infection were not fully aligned to the current Dublin Midlands Hospital Group, whereby a consultant microbiologist and an assistant director of nursing provided a regional service across three hospitals and had a remit in two Hospital Groups; the Dublin Midlands Hospital Group (in the case of hospitals in Portlaoise and Tullamore) and the Ireland Hospital East Hospital group (in the case of Midland Regional Hospital, Mullingar).

 The microbiologist provided cover to three acute hospitals over two Hospital Groups, including a clinical advice service, twenty four hours a day, seven days a week. HIQA said hospital management should review this arrangement, given the required workload relative to resourcing levels found in other similar hospitals, in the interest of ensuring continued sustainability.

While the hospital had a suite of up-to-date infection prevention and control policies, staff in clinical areas had some difficulty accessing policies, procedures and guidelines stored electronically. In addition, clear written communication about patients’ infection control assessment or infectious status, prior to transfer from one department to another during hospitalisation, was not always evident.

Staff attendance at regularly scheduled hand hygiene training requires improvement as only 65 per cent of hospital staff had attended hand hygiene training in the previous two years.

In light of the suspension of the previous programme of surgical site infection surveillance and the revised surveillance programme now in place, management of surgical site infection surveillance requires further review to ensure that it is effectively structured, resourced and governed by senior management so that they are assured of the safety of surgical services provided.

The hospital had implemented a suite of evidence-based practices (care bundles), but audits were not carried out on a regular basis.

The general environment and equipment in the areas inspected were clean and well maintained with some exceptions. HIQA recommends the frequency of auditing of very high risk areas is increased in line with national guidance.

Portiuncula University Hospital:

An unannounced inspection of Portiuncula University Hospital took place on 6 February 2018.

The hospital had ensured that screening patients for CPE was fully embedded in the hospital in line with national HSE guidelines.

Governance arrangements were in place to support the prevention and control of healthcare-associated infection, with well-established links with the Saolta University Health Care Group.

Hospital management and the Infection Prevention and Control Team had developed and implemented elements of a monitoring and evaluation system.

Organisational reporting structures at the hospital could be further advanced by formalising arrangements to an oversight committee at the hospital.

At the time of the inspection 84 per cent of hospital staff had attended hand hygiene training in the previous two-year period. The hospital had exceeded the national HSE compliance target of 90 per cent with hand hygiene practice in October 2017.

The hospital had a suite of evidence-based practices (care bundles). Care bundles were fully implemented in the Intensive Care and Coronary Care Unit and compliance audit results showed consistent good practice in recording interventions.

Inspectors were informed that the hospital did not routinely perform surveillance of surgical site infection and had no policy to guide staff. This does not comply with recommendations in national guidelines, stated HIQA.

The management teams “should ensure that relevant information produced through local monitoring is accessible to front-line staff”, noted the Authority.

The patient environment inspected was generally clean with few exceptions. However opportunities for improvement were identified in relation to the management of patient equipment hygiene and auditing schedules for hospital hygiene.

In addition, auditing schedules in relation to hospital hygiene should be reviewed and information tracked and trended.

The dated hospital infrastructure, lack of isolation rooms and en-suite facilities, multi-occupancy rooms and space restrictions, as identified by the hospital and previous HIQA inspections, remains a challenge in relation to the implementation of an infection prevention and control programme.

Cappagh National Orthopaedic Hospital, Dublin:

An unannounced inspection of Cappagh National Orthopaedic Hospital, Dublin took place on 15 February 2018.

The hospital had not successfully ensured that screening patients for CPE in line with HSE guidelines was fully embedded at the hospital. HIQA escalated concerns related to this finding to the hospital in writing following the inspection. Hospital management responded by highlighting key actions which the hospital has instigated to address this risk.

Effective leadership, governance and management arrangements were evident. The hospital had an established infection prevention and control programme which was overseen by a consultant microbiologist.

The fabric and infrastructure of the hospital “continues to present ongoing challenges to the maintenance and upkeep of the building”, resulting in limited isolation for patients with transmissible infection. The hospital continued to revise and strengthen local arrangements for managing hospital hygiene and infrastructural maintenance since the last HIQA inspection in 2016. Patient equipment and the environment were generally clean in the areas inspected.

The hospital had systems in place to identify and manage risks in relation to the prevention and control of healthcare-associated infection and had established a local system of surgical site infection surveillance. The hospital had exceeded the national HSE compliance target with hand hygiene practice.

Peripheral vascular and urinary catheter care bundles were in place. However, improvements are required to auditing compliance with the peripheral vascular catheter care bundles and providing feedback to staff.

St Vincent’s University Hospital, Dublin:

An unannounced inspection of St Vincent’s University Hospital, Dublin took place on 26 February 2018.

The hospital had not successfully ensured that screening patients for CPE, in line with national HSE guidelines, was fully embedded at the hospital. HIQA escalated concerns related to this finding to the hospital in writing following the inspection. Hospital management responded by highlighting key actions which the hospital has instigated to address this risk.

The hospital had identified this issue as an area of concern prior to this inspection and sought assistance in dealing with this risk, according to HIQA. The CEO provided assurances to HIQA that the hospital was actively managing this risk to mitigate any possible impacts on patients in the interim of additional resources required to support the full implementation of CPE screening guidelines.

Inspectors found that effective leadership, governance and management arrangements were evident around the prevention and control of healthcare-associated infection. HIQA noted and acknowledged that following recommendations from a prior inspection, the National Liver Unit was relocated to a more appropriate ward setting from an infection prevention and control perspective.

Staff had access to up-to-date policies, procedures and guidelines. Overall, the patient environment inspected was generally clean with few exceptions. The hospital has consistently exceeded the national HSE compliance target with hand hygiene practice.

The hospital had implemented targeted surgical site infection surveillance which is an important patient safety and quality assurance initiative. Opportunities for improvement were identified in relation the management and audit of patient equipment cleanliness.

South Infirmary Victoria University Hospital, Cork:

An unannounced inspection of South Infirmary Victoria University Hospital took place on 13 March 2018.

The hospital had not successfully ensured that screening patients for CPE in line with National HSE guidelines was fully embedded in the hospital. HIQA escalated concerns related to this finding to the hospital in writing following the inspection. Hospital management responded by highlighting key actions which the hospital has instigated to address this risk.

The hospital was not in compliance with CPE national screening guidance. In addition, CPE screening criteria applied locally by the hospital was limited to screening patients in nightingale-style wards only and excluded patients who were transferred from or had been inpatients in hospitals in Cork and Kerry, rather than in accordance with national guidelines. This was of significant concern to HIQA.

Infection prevention and control governance structures and systems were in place to identify and manage risks in relation to the prevention and control of healthcare-associated infection. However, HIQA notes that infrastructural deficiencies and limited space at the hospital continues to present ongoing challenges with a potential to impact on the effective implementation of infection control practices.

Increased monitoring of hospital hygiene between 2016 and 2017 indicated staff hand hygiene compliance above 90 per cent. The hospital had introduced a postal screening option for pre-assessment of patients by telephone prior to admission. However, further improvement was required in relation to care audits and peripheral intravascular care bundle audits.

Royal Victoria Eye and Ear Hospital, Dublin:

An unannounced inspection of Royal Victoria Eye and Ear Hospital, Dublin, took place on 14 March 2018.

The hospital had successfully ensured that screening patients for CPE was fully embedded in the hospital in accordance with national guidelines.

Effective leadership, governance and management arrangements were evident around the prevention and control of healthcare-associated infection on the day of inspection.

The hospital had a planned and organised monitoring and surveillance programme with clear oversight of performance across the hospital. The hospital had implemented targeted surgical site infection surveillance which is an important patient safety and quality assurance initiative. Inspectors found that the hospital had a suite of infection prevention and control policies to guide and inform staff.

Care bundles had been implemented with an audit and feedback programme in place. At the time of the inspection 90 per cent of relevant staff had undergone hand hygiene training in the previous two year period. The hospital needs to continue to build on achievement to date to ensure that the hospital achieves and maintains the required national hand hygiene compliance target set by the HSE.

Overall the patient environment inspected was generally clean with few exceptions. An electronic hospital auditing system facilitated regular trending, analysis and oversight of audit results at both local and senior management level. Opportunities for improvement were observed in relation to the management and storage of patient equipment.

The Royal Victoria Eye and Ear Hospital dates back to 1897 and therefore was not aligned to modern healthcare facility requirements. Some of the challenges faced by dated infrastructure included nightingale-style wards, a lack of isolation rooms with en-suite facilities and a lack of operating theatre ventilation systems.

Collectively these deficiencies do not facilitate the full implementation of an infection prevention and control programme in line with National Standards and therefore need to be substantively reviewed and addressed. Hospital management should be fully supported at both hospital group and national level in this regard.

St James’s Hospital, Dublin:

An unannounced inspection of St James’s Hospital took place on 21 March 2018. While the hospital had implemented a high level of compliance with the multi-drug resistant organisms screening guidelines, screening of all patients for CPE as required by national HSE guidelines was not fully embedded in the hospital. In the absence of full screening, the hospital had implemented a programme of weekly ward-based CPE screening.

 As screening patients for CPE was not fully embedded in the hospital, HIQA escalated concerns to the hospital in writing following the inspection. Hospital management responded by highlighting key actions which the hospital has instigated to address this risk.

Effective leadership, governance and management arrangements were generally evident around the prevention and control of healthcare-associated infection. Management had actively addressed issues previously identified in the unannounced HIQA inspection carried out in 2014.

Clear oversight of performance across all clinical areas was led by the Infection Prevention and Control Team. In the absence of a nationally coordinated programme, the hospital had established a local system of surgical site infection surveillance.

The hospital had worked to implement a number of core antimicrobial stewardship interventions. However, HIQA said it is essential that ongoing, higher than national average rates of Clostridium difficile infection are proactively prevented and controlled. The hospital should review current processes related to the cleaning and disposal of bedpans to ensure they do not increase the risk of spreading infection.

In addition, it is recommended that the hospital review the current approach to restrictive prescribing rights for certain antimicrobial agents. If hospital rates of Clostridium difficile infection are to be effectively reduced, the antimicrobial stewardship programme requires the full support of the executive management group and hospital consultants.

St James’s Hospital had demonstrated commitment to improving hand hygiene awareness and practices. Moreover, essential controls were in place to protect patients from the risk of acquiring invasive aspergillosis – something that was especially important at the time of the inspection given the level of building work ongoing on the hospital campus.

The patient environment in three areas inspected was found to be generally clean. The hospital had also significantly improved its approach to oversight and assurance of cleaning performance following prior recommendations by HIQA in a previous inspection.

Significant improvements had also been made in relation to hospital infrastructure with the building of the new Mercer’s Institute for Successful Ageing (MISA) facility which officially opened in December 2016.

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