On 7 November 2018 the Health Information and Quality Authority (HIQA) undertook an unannounced inspection at Cork University Hospital, against the National Standards for the prevention and control of healthcare-associated infections in acute healthcare services. 

During this inspection, a number of high risks were identified in relation to the management of an ongoing outbreak of Carbapenemase-Producing Enterobacteriales (CPE) – a very resistant type of bacteria that can cause serious infections. CPE is a public health emergency and there is a need for rigorous adherence to national standards and best practice in relation to outbreak control measures to properly protect patients.

This inspection raised significant concerns for HIQA around the overall approach taken at Cork University Hospital to effectively manage risks to patients from infection and colonisation with multidrug-resistant organisms. Similar to findings during HIQA’s 2017 inspection, inspectors found that governance arrangements at the hospital needed to be significantly strengthened in relation to the prevention and control of healthcare-associated infection.

While the hospital had acted to implement outbreak control measures to manage the ongoing CPE outbreak, HIQA was not assured that the measures implemented were sufficiently effective or in line with National Standards and guidelines. Specific deviation from expected outbreak control measures identified during this inspection included: 

• the cohorting of patients with CPE in a multi-bed room without toilet, shower or hand hygiene facilities 
• cleaning, monitoring and auditing were not in accordance with required standards to effectively deal with an outbreak situation. 

Following the inspection, HIQA sought written assurance from the Chief Executive Officer (CEO) regarding the management of CPE within Cork University Hospital. The CEO outlined key actions which the hospital had introduced since the inspection to mitigate the risks identified by HIQA. 

Full details are included in the inspection report below.

Notes to Editor:

• A National Public Health Emergency Plan was activated on 25 October 2017 by the Minister for Health in response to the increase and spread of Carbapenemase-Producing Enterobacteriales (CPE) in Ireland. A National Public Health Emergency Team was convened. Further details as to the work of this team may be viewed here.   
• Carbapenemase-Producing Enterobacteriales (CPE) is the newest in a long line of 'superbugs' (bacteria that are hard to kill with antibiotics). Of all the superbugs, CPE is among the most difficult to kill with antibiotics. It is carried in the bowel and can cause blood stream infection in people who are vulnerable, such as the elderly and those with low immunity. More than half of all patients who develop blood stream infections with CPE die as a result of their infection. Further details may be found on the Health Service Executive (HSE) website. 
• People may be either colonised or infected with CPE. People who are colonised with CPE have the bacteria present in a part of their body (usually in the bowel) where it lives without causing an infection. Infection can occur when the CPE bacteria is either directly introduced to, or enters other parts of the body which are normally sterile such as the bloodstream. Screening for CPE in patients who have risk factors that make them more likely to be colonised is a critically important control measure because knowing who is colonised can allow measures to be put in place so that they are better protected from risk of infection, and so that the bacteria does not spread further to other patients or staff. 
• The HSE identified that screening patients for colonisation with CPE was a key control measure to effectively manage this issue. Knowing if a patient is colonised with CPE allows hospitals to better reduce the risk of colonised patients going on to develop CPE infection during the course of their medical treatment. Screening also enables the hospital to better prevent potential spread of CPE to other patients and staff. Targeted screening has been shown in other health systems to effectively reduce the potential for both infection and spread of CPE.